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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTO14 CA 95202 - (209)468.3420 i <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �+ ^ z � <br /> JOB ADDRESS q3R W r�,LI([]OL� C17Y121P �L h�.� T (l� D <br /> �� 1�3i�05a <br /> �CROSSSTREET r APN PARCEL SIZE LAND USE APPLICATION# Z <br /> OWNER NAME .-_ PHON <br /> OWNERADDRESS � w. r� - , s R -- CITY!$TATEIZIP <br /> CONTRACTOR L2At�C - _ LPH�ONE . C1������'I <br /> -CONTRACTOR ADDRESSZTI"^ YV L0 CITY/STATE/ZIP III <br /> SUBCONTRACTOR __ PHONE <br /> SUBCONTRACTOR ADDRESS _ _- __ CITY/STATE/ZIP _ <br /> LICENSE )0c-57 L C-61 ] D-09 J Other NUMBER�l3 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE yDomestic/Private C Irrigation/Agricultural D Industrial D Water Quality Monitoring I_Soil Sampling/Characterization <br /> Ir <br /> C Public Water System __-. _ - —_ <br /> If tlitferantfrom Owner, er ys enname a _me or Phone NUMber <br /> TYPE OF WORK New Well J Replacement Well r'Well Alteration/Modification C Other <br /> F of borings #of borings <br /> - Monitonng Well(s) #of wells C Soil Boring(s) G Geotechnical <br /> Out-Of-Service Well C Out-Of-Service Weil Renewal C CrOSS-Connection Repair <br /> = New Pume XPumpReplacement C Pump Repair r- Raise Well CasingV� <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary i'Air Rotary 7 Auger C Cable Tool Push Point n Other <br /> Proposed Well Depth ft Excavation in diameter D Open Bottom D Gravel Pack/Gravel Size _ in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Scned C Steel -1 Plastic -1 Stainless Steel Fi Other <br /> Grout Seal Depth ft D Neat Cement(94 to bag/5-10 gat water) -1 Sand Cement sack mix/7 gal water <br /> ,:Bentonite(20%solids) D Other <br /> Grout Placement Method L Pumped 7 Free Fall D Other r- Retardant/Accelerator(name) �ttt <br /> PEDESTAL Installed By C Driller D Pump Contractor I Other <br /> --Concrete Pedestal Dimensions:Width ft Length ft Thick in 7 Christy Box 0 Stove Pipe <br /> PUMP 'XSubmersibieL Turbine 7 Other HP Pump Set_jGq_ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT�J HAVE P ED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDI /(N S, AT LAWS, AND RULES AND REGULATIONS: I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE JW #THVCAJORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATl !I <br /> HOUR ADVANCE NOTICE UI D FOR INSPECTIONS _ <br /> SIGNED TITLE DA7Et <br /> I <br /> AY <br /> RE <br /> I <br /> UTY <br /> I <br /> 09 ! <br /> I I <br /> I <br /> H H E A <br /> I <br /> i <br /> I <br /> i <br /> i I ' <br /> I <br /> DEPARTMENT USE ONLY /—/ <br /> Application Accepted By Date �� Q Area Employee ID# `PULES / 119 <br /> Grout Inspection By Date U SPECIAL Well Permit I <br /> Pump Inspection By Date 0 _—. fl WAIVER Received <br /> Soil Boring Ins ction By Date Constructed Well Depth ft <br /> COMMENTS 714 -- <br /> PE SC Received h c AmountDate Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted q Service Request# <br /> cF3�l pso 5 p iso. ,�i o � Shoos-8�c�g' � 00315`f <br /> '� EMD/13-06 WfLL'PUMP PERMIT <br />