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VVELUPUMP PERNT <br /> ,)AN JOAQUIN CouN, f ENVIRONMENTAL HEALTId DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> ti' 0N-REFUNDABLE PERMIT CALL 209 953-76997 FOR INSPECTIONS (EXPIRES 11 YEAR FROM DATE ISSUED <br /> JOC MDDRESS 1 I677 6 Imt l{d N 12-GCIn/ZIP Me1 4 1 ee-Q - l / S337 _I <br /> m <br /> 0 <br /> CROSS STREET Y`��A`tAAGalPARCEL SIZE IO.O O LAND USE m <br /> CiWiVL=RI'11-1NIE1.1r�1Q� �il�� �AlYv L� PHONE (Q q /L <br /> OIIVNER:0DRESS •V •p ClTY/STATE/7-iP 91.00v1 <br /> CONTRACTOR J IOIVLc <br /> CONTRACTOR ADDRESS Dot ot A�T 0 1�-�( CI-t /STAT EIZI1, j�)�a <br /> SUBCONTRACTOR FNONE <br /> SUBCONTRACTOR ADDRESS CITY/S T ATE/ZIP <br /> LICENSE 1-16-C-57 0 C-611 ❑ D-09 0 Other NUMBER EXPIRATIONDATE • <br /> GEOGR^,P'rI1CAL INFORM,QTION: Coordinates,( Y Township Range Section <br /> INTENDED USE Domestic/Private ❑ hTigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE Or-WORK 111eW W@II 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) ##of wells ❑ Soil Boring(s) 1A of borings 0 Geotechnical ft of borings <br /> 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 0 New Purn i 0 Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling i'dlethod�<Mud Rotary ❑Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 246 ft Excavation I I II_ in diameter 0 Open Bottom Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched 00 ❑ Steel KPlastic 0 Stainless Steel 0 Other <br /> Grout Scat Depth O it 0 Neat Cement(94 lb bag/5-10 gal wate/) ❑ Sand Cement sack mix/7 gal Water <br /> XBentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped 0 Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL installed by 0 Driller ump Contractor ❑ Other <br /> 0 Concrete Pedestal Dimensions:Width it Length ft Thick in 0 Christy Boy[ 0 Stove Pipe <br /> l�uMP 0 SubmorsibleO Turbine 0 Other HP Pump Set it `Standing Water Level ft <br /> I HERECY CERTIFY TH10.i I HAVE PREPARED THIS APPLICA71ION AND THAT THE WORK, WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REOULAT IONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND T HA1.I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSAT[ON LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQPIRED FOR INSPECTIONS y <br /> SIGNED 1 L tie • DATE �_ 7 <br /> I <br /> IV I <br /> i <br /> --- — — — <br /> PA <br /> T11 M <br /> Tr <br /> --F IVIRONM N_ <br /> HU-THIDEPAR ENT <br /> 44-1 O A R T M ENT S E_-/ N L Y <br /> Application Accepted By DaL QA J, Aread6Nq Employee ID#26_14� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil 0011,11D l ispection By Date Cons'truc'ted Well Depth tt <br /> COMMENTS A-11"r uur <br /> PE SC Received ChecloN Amount Permit/Codes lnfo By Cash Remitted Date Service Request; Invoice# Well ID{ <br /> �G ( �0 003PIq5�S <br /> Q11119(9 9q1 <br /> d 8 (2 l 3 <br /> EI-ID 43-00 WELL/PUMP PERMIT <br /> SiO4iG6 <br />