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6130 .Goy <br /> WELL/PUMP PERMIT � Aa <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 -(209)464-3420 b <br /> NON-REFUNDABLE <br /> (PERMIT /� ',,n,�.{(CALL 22/-0/�9)/9,�553--7697 FOR II',sPECTIONS EXPIRES I YEARRFROM DATE <br /> `ISSUED <br /> ��� <br /> 30B ADDRESS 2.3 �� /✓�/L Y4YL 1''•frh Pte'+'•+� P� CITY/ZIP /{_11/t'L�� sLJY�}_.�1. ' y <br /> � nYGl//� O <br /> CROSS STREET APN i7 .tJ —ZfcP PARCEL SIZE-13f I q�LND USE APPLtCAT10N# po <br /> OWNER NAME PHONE 4G^i <br /> OWNER ADDRESS p / / CITY/STATE/ZIP <br /> CONTRACTOR 2 .� <br /> ,f_/I�d 1 p��7 4�'L • PHONE <br /> CONTRACTORADDRESS-�� ` jb CITY/STATEIZIP -5j�t <br /> SUBCONTRACTOR ` ' I PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATFJZIP <br /> LICENSE 0jC-57 ❑C-61 ❑D-09 ❑Other NUMBER 2— EXPIRATION DATE / Q <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring CKSoil Sampling/Characterization <br /> ❑Public Water System <br /> If diR I Rom Ow ager yarom ame -Mv Narne or Phone u r <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Weil Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #ofwells ❑Soil Boring(s) #ufbudnga Geotechnical aor borinpt <br /> Cl put-0f-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION 1 <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth S---2-0 ft Excavation I/Z 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/Gauge/ASTM Scholl ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/-I-10 gal water) ❑Sand 'emerlt • sack mix/7 gal water <br /> ❑Bentonite(20°/a solids) ❑Manufactttrer Spec%solids % Name , �'o_ /f ❑Specs on File ❑Specs Submitted <br /> Crout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/ ele Ira or tame) <br /> Acc <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 /> 1 HEREBY CERTIFY THAT 1 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 i AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRE[)FFO,I$IN{S\/P�,ECT )NS <br /> SIGNED �L,.-1-�)ti/ TITLE :i T�1 uy G'IJI"Y DATE <br /> I t <br /> IF <br /> 11B 115 <br /> t S <br /> r <br /> S / <br /> P. <br /> 22 <br /> D M E N T USE ONLY <br /> Application Accepted Date Area Employee ID# rJ <br /> Grout Inspection B Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date _ ❑ WAIVER Received <br /> Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B asTi� Remifted Service Request# - <br /> 5b / Ca Sr42019 <br /> EH D 43-02-006 WELL PUMP PERMIT <br /> 1/27/2005 <br />