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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-T6 OR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 1.� 4 cITY21P L Gs L1C�._ <br /> m <br /> JOB ADDRESS - D <br /> CROSS STREET APNPARCEL SIZE 43 LAND USE APPLICATION#_ m <br /> u <br /> Q w <br /> ) � <br /> OWNER NAME - <br /> PHONE <br /> 5`" CITYISTATE/ZIP n� CITY/STATE/ZIP <br /> OWNER ADDRESS _ — <br /> Lj <br /> CONTRACTOR PHONE <br /> V <br /> CONTRACTOR ADDRESS � <br /> SUBCONTRACTOR PHONE .. <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / <br /> (LICENSE C-57 C-61 -1 D-09 UOther NUMBER . '`" EXPIRATION DATE (C .` -3-- <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE Domestic/Private J Imgation/Agricultural 0 Industrial D Water Quality Monitoring -I Soil Sampling/CharaClefIZ2bon <br /> u Public Water System un ame or ne um r <br /> _ If OHerern from Owner. 7Q uY Ys arae <br /> TYPE O DF W RK a New Well U Replacement Well 0 Well Alteration/Modification 0 Other <br /> uoroonngs <br /> U Monitoring Well(s) #of wells ❑Soil Boringsoroonngs -1 Geotechnicals) r <br /> Out-Of-Service Well D Out-Of-Service Well Renewal C Cross-Connection Repair <br /> \i6ew Pump i Pump Replacement C Pump Repair r Raise Welt Casing _ _7 <br /> WELL CONSTRUCTION <br /> Drilling J Mud Rotary C Air Rotary 7 Auger r-Cable Tool G Push Point E Other <br /> Proposed Well Depth ft Excavation in diameter J Open Bottom J Gravel Pack/Gravel Size in diameter <br /> F.Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad D Steel L Plastic J Stainless Steel j Other <br /> Grout Seal Depth It U Neat Cement(94/b bag/5-10 gal water) C Sand Cement Sack mixr7 gal water <br /> I.I Bentonite(20%solids) C Other <br /> Grout Placement Method i-)Pumped O Free Fall J Other 0 Retardant/Accelerator(name)_-_ <br /> IPED� Installed By D Driller J Pump Contractor F Other <br /> C Concrete Pedestal Dimensions:Width ft Length ft Thick In rChristy Box C Stove Pipe <br /> PUMP i'SubmersibleC Turbine J Other HP Pump Set ft Standing Water Level—1.7to—'t 'r <br /> I HEREBY CERTIFY THAT I 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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> j"UM 24 HOUR ADVANCE NOTICE REQ, I D FOR INSPECTIONS <br /> TITLE U 1 oA,E r <br /> Ll <br /> r <br /> J <br /> I <br /> I <br /> FE v <br /> I <br /> UL r <br /> 5 H A'i rMt�T L <br /> YJ.o . <br /> g. <br /> II <br /> r I <br /> DEPARTMENT USE ONLY <br /> I Application Accepted By Date ^ y� 1�/ Area Employee lD#J <br /> Grout Inspection By o Date C SPECIAL Well Permit <br /> Pump Inspection q 1 <br /> Date l l -1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTs <br /> I - <br /> F7E Sc Received ec Amount ;Date, PennrU Invoice# Well ID# <br /> Codes Info 8 Remitted Service Request# <br /> 438b OS lS(Lu o c�2-7N <br /> t _ <br /> EHD 43-06 I WELL tPUMP PERMIT <br /> 1 BG/IOfl <br />