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WELL/PUMP PERMIT %r5 - % - <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"o FL-STOCKTON CA 95202 .(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL, 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> � �A( /I ` s <br /> JOBADDRESS.. `SrI7� C17Y/ZIP II/ <br /> ' m <br /> CROSS STREET W Q APN22Z-704;�%L'A'ARCEL S12E��-E USE APPLICATION# <br /> *1\ �^c <br /> OWNER NAME 'lu `�, <br /> OWNERADDRESS �C-S�Y1J S.{��LL-S Tt,r1 f�C•• CITY/STATFIZIP � ��{S- p�✓�,�.J36.G' <br /> COrdl'RACTOPHHONJE -�/��O <br /> CONTRACTORR [� <br /> ADDRESS I a,PNS '�(, CITY/STATEIZIP / e,-e -/r«T O r (/ 1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/SSTATFJZIP y � <br /> LICENSE )C-57 ❑C-61 ❑D-09 ❑Other NUMBER ZIZ- �7- EXPIRATION DATE /-e'L'!J <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If diRerent from Owner: Water System ame Coomt Name or Phom Number <br /> TYPE OF WORK( New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) x ufbormp ❑Geotechnical #of boring, <br /> ❑OutOf--Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair N <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair 1 <br /> WELL CONSTRUCTION ^ <br /> Drilling Method P*ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other V Ir <br /> Proposed Well Depth 2297 ft Excavation/�in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conducto as ng in diameter / Conductor Casing Depth H <br /> Well Casing Diameter m Thickness/Gauge/ASTM Sched �,� L " ❑Steel %61.stic ❑Stainless Steel ❑Other <br /> r <br /> Grout Seal Depth R ❑Neat Cement(94/b bug/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> (Bentonite(2V16 Solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method CR3!pmped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) `r�R <br /> PEDESTAL Installed By ❑Driller mp Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe v <br /> PUMP ❑Submersible ❑Turbine ❑Other IIP Pump Set R Standing Water Level It <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN J <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> JM wM,I,NIIM//�LSI%VI_24 HOUR ADVANCE NOTICE'a'�`REgUIRED FOR INSPECTIONS <br /> SIGNED I.�(,~C- / 'tt-kt-L Kl TITLE `J k� ( rY✓t DATE <br /> L <br /> 7? <br /> l <br /> E' <br /> r r - <br /> 'It r <br /> IT- <br /> � E rR T M E N T USO L Y - - - --- '- - --- <br /> Application Accepted By �- \ to Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well De p[h ft <br /> COMMENTS <br /> PE SC ReceivedCheck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info as Remitted Servi a uest# <br /> /8 / Z LUPO3 D io SZ <br /> EHD 43-02.006 WELL PUMP PERMIT <br /> 1(272005 <br />