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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3 Y FL-STOCKTON CA 95202-(209)469-3420 <br /> NON-REFUNDABLE/PERMIT CALL(209)//953(---7/697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS `7✓ ( �V(/!Ll GtL�Y CITY/ZIP <br /> CROSSSTREET /`!GJ-��F%Y�l APNC07i'�O�� PARCEL IZ�- LAND USE APPLICATION# 70 <br /> OWNER NAME l lav f !/a, e-�/ -sup - PHONE <br /> OWNER ADDRESS U ✓Y//it i R/L�G�f CrTY/SfATEJZIP�S�+-Y.Id��J/�t-�4�j C/c j V 3 l <br /> CONTRACTOR P/HONE <br /> CONTRACTOR ADDRESS S(/t-( ✓L/ iJ t- Crry/STATFIZIP �y <br /> SUBCONTRACTOR PHONE .� <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDEII USF ❑Domestic/Private ❑Imgation/Agricultural ❑Industnx ❑Water Quality Monitoring ❑Soil Sampling/Charactenzation <br /> ❑Public Water System <br /> If diff i Cram 0wn<. Witm ystem N.— ontact,wnt or hum <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of Wells ❑Soil Bonng(s) #of bonngs ❑Geotechnical 4 of borings <br /> )B:�ttt-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Rump Replacement ❑Pump Repair <br /> Wm.i,CONSTRU(-rioN <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gaugc/ASTM Schcd ❑Steel ❑Plastic ❑Stainless Steel ❑Other \ <br /> Grout Seal Depth ft ❑Neat Cement(94 16 bag/S-!0 gal 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 ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) _ <br /> PFDE-At. Installed By ❑Driller 13 Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> Pl%MP O Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ftp\\\ <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN h'\ <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 r� <br /> WORKERS COMPENSATION LAWS. <br /> IN[MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS �7 <br /> SIGNED TITLE J LW/O�CZ�(/ DATE <br /> \\ <br /> jC ,; Ih a LINTY <br /> AL <br /> F F ENT <br /> DEPARTMENT USE ONLY (Qy <br /> Application A ed By Date �/� Area Employee IN <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth It <br /> COMMEN .0 cC <br /> 1 <br /> PE SC Received Checkit/ Amount Permit/ <br /> Codes Info By as Remitted Date Service Request <br /> # Invoice# Well IB# <br /> EHD 43-3.006 WELL PUMP PERMIT <br /> 1272005 <br />