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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (209, <br /> NON-REFUNDABLE PERMIT t- bCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE <br /> JOB ADDRESS <1 r�r.., l V�I r J 1 l�.1'i�f C CITv/ZIP f� t._ L� "-7 <br /> CROSS STREET `_ �� T� �C C <br /> r APN ) T` CEL SIZE LAND USE APPLICATION# A <br /> OWNER NAMEi7 / r i. 1 PHONE {_ .L , ' <br /> OWNER ADDRESS �.-r R11���C i ��C-. j t'� t1�� CITY/STATE/ZIP t' .14(a i A t if <br /> CONTRACTOR �t1. 0 i I ICxC�+I(.f )�; I 1 C_ PHONB <br /> CONTRACTOR ADDRESS _)..� ,V•`U f krI/'; CITVISTATEIZIF"l 1 \'l I' i ( .A �`- 1(1;6; <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑Cfil ❑D-09 W Olhct l 'i i NL:MBER -�c�2 Z EXPIRATION DATE L• <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ ISS <br /> INTENDED USE 0 Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charactenzation <br /> ❑Public Water System <br /> Vdifferent from Owner. e[er yftem eme onuct Name or one.u <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Wcll(s) #ofwells ❑Soil Boring(s) Morbodnas ❑Geotechnical____-rofborings f� <br /> ❑Out-Of--Service W II ❑Out-0f-Service Well Renewal ❑Cross-Connection Repair l�h <br /> 13 New Pum Pum R lacement O Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> Cl Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter__in Thickncss/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ih bug/S-)0 gal wirer) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> Pua+r6iSubmersible ❑Turbinc ❑Other HP Pump Set fl Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK RILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSA N LAWS. <br /> f� MINI LM 24 01-R VANCE NO'TICCE�RREQUIRED FOR INSPECTIONS <br /> SIGNED / !- TITLG "-- DATE <br /> D <br /> NUT <br /> 7-tj 01 <br /> R <br /> I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By U�l <br /> G� Date 1 L`1� — Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspxtion By I Date�� cZL�QS ❑ WAIVER Received <br /> Constructed Well Depth (1 <br /> COMMENTS <br /> i PE SC Received hec Amount Date Permit/ Invoke# WeIIID# <br /> Codes Info B - Remitted Service Request# <br />