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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENwRONMENTw-_-LALTH DEPARTMENT 304 E WEBER AVE L-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDADLE PERMIT CALL. 209) 53-'697 'OR INsm1' TIO\S EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 4e/i ' ee Clly/L� a T9!57& 3 Z <br /> I m <br /> r s'D <br /> i o <br /> CROSS STREET II e Ad. ApN PARCEL SIZE LAND USE APPLICATION# G A <br /> OWNER NAME �r4/G/ a (�` PHONE��r7`f4(/ <br /> _ OWNER ADDRESS O � 't CITY/STATE/LIP <br /> sto1p CONTRACTOR PHONE <br /> t (CONTRACTOR ADDRESS I CITY/STATE/LIP <br /> CONTRACTOR PHONE r���'Tye•�= ' <br /> F <br /> ONTRACTOR ADDRESS C /STATE/LIP <br /> NSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER AG Z-tv EXPIRATION DATE 3D.OL <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> TENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sa pling/Characterization <br /> ❑Public Water System / Q <br /> If different from O•.ner: nc ynem me onteol,eme a one um <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> >'Lvlonitoring Well(s)�#of wells �i'Soil Boringp of boring <br /> s) s Geotechnical M of borings <br /> ! • <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair bD r I��S <br /> ❑New Pum ❑Pum Replacement ❑Pum Repair <br /> W ELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger F ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation `Ein diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing 2(A in diameter / Conductor Casing Depth it <br /> Well Casing Diameter 2 in Thickness/Gauge/ASTM Sched ❑Steel MI Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depths ft j0la4eat Cement(94 lb bag/5-10ga/water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method m ed ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By •Driller ❑Pump Contractor t ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width_�ft Length fl Thick in XChristy Bos ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level fl <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 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 CALIFO IA CO CTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> I 1; H URA ANCE NOTICE REQUIRED F RINSPEC NS <br /> SIGNED TITLE <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date a� Area _ Employee Hlb � 7 <br /> Grout Inspection By Date Z r 1 a 0 SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth R <br /> COMMENTSAG�� t��/�4E CHK{�c� �I�r 4S3-rco /e �tft'rL • �i'Suc7 A�I/J <br /> PE SC Received Check#/ Amount Permit/Date Invoice# W'cll IUN <br /> Codes Info By Cash Remitted Service Request# <br /> �- �•QI_��q°s L �'1 � 4204 � <br /> EM 43-02-006 WELL PUMP PERMIT <br /> trztnoos <br />