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WELL/PUMP PERMIT t <br /> 3a <br /> SAN JOA IN'COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP � ,, <br /> i Y <br /> d <br /> ' CROSS STREET APN z`r-r- PARCEL SIZE 30'6 r LAND US PP/PLLICATION##7 <br /> ! OWNER NAME I r PHONE <br /> i OWNER ADDRES <br /> ✓C/O / A I a�Cr1Y/STATE/ZIP <br /> CONTRACTOR / t-(.(� W/ `G �PHONE <br /> f <br /> CONTRACCOR ADDRE CITY/STATE/ZIpi // <br /> SUBCONTRACTOR <br /> ` HONE C/ <br /> SUBCONTRACTOR ADD- CITY/STATE/ZIP <br /> LICENSE K-57 ❑Cbl ❑D-09 ❑Other NUMBER 34Q/LY EXPIRATION DATE <br /> GEOGRAPHICAL INTO ION: Coordinates X Y Township Range Section <br /> INTENDED USE mestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different form Owner: Water System Nam Comact Nsme or Phone Number <br /> TYPE OF WORKC141K Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) a of borings ❑Geotechnical #of borings <br /> ❑Out-Of--Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> ' WELL CONSTRUCTION <br /> I <br /> Drilling Method ud Rotary ❑Air Rotary ❑Auger f� ❑Cable Tool ❑Push Point ❑Other <br /> F Proposed Well Depth C21fif— It Excavation� in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size- in diameter <br /> ` ❑Conducto asrng in diameter / Conductor Casing Depth ft <br /> Y Well Casing Diameter in Thickness/Gauge(ASTM Sched ❑Steel tic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 105r'r ft ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> UI B ntonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted a <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) -� <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width it Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN O <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS h <br /> i CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL �J <br /> WORKERS COMPENSATION LAWS. (� <br /> ,�IINIYUK24 HOUR ADVANCE NOTICE RE RED FOR INSPECTIONS <br /> 1 SIGNED TITLE DATE (� —�—057/ I_ <br /> 4 ' <br /> JJ ID I I <br /> VIF <br /> ) t <br /> (I <br /> I <br /> I <br /> Ol, 4E IM IL <br /> EN F <br /> TH D <br /> --_—_ --' -.\-- -/r`.:(.n/cD--•- - DEP A'R N U' �N_,�..•, _ _ - _ _��_��-�v -�/'_ _ � . <br /> Application Accepted By Date 4�0 Area Employee ID# <br /> Grout Inspection By to �Z ❑ SPECIAL Well Permit <br /> t Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> CO TS O OF �.[I <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes info B Cash Remitted Service Request# <br /> 4T L-4 /T-0 W 5 00 50 53 6 Z4,-7 <br /> EHD 43-02-006 WELL PUMP PERMIT <br />