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I <br />WVELLIPUMP PERMIT <br />SAN JOAQUIN COUNT Y ENVIRONMENTAL HEALTH DEPT '1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT UALL .41.11y y55 -/by! FOR INSPECTIONS LXPIKLb 'I YEAR FROM FROM UATE/ISSUED <br />Jos ADDRESS <br />\\ n,­.41� { CITY/Zipgb"MLJr'J <br />CROF <br />ss <br />STRE II, C \ %W_ APN 0 J PARCEL SIZE/LJ J LAND USE APPLICATION # <br />OWNER NAME 1 PHONE �tJ-1 + (069 19 1 <br />OWNER ADDRESS ` -3K�w5 <br />CONTRACTORr <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR <br />LICENSE ;61,C-5 <br />J <br />ADDRESS ITY/STATE//ZZIP PHONE <br />Alv- <br />7 ❑ C-611 ❑ D-09 ❑ Other NUMBER (QEXPIRATION DATE I I <br />iEOGRAPHICAL'INFORMATION: (;oorcunaxes X <br />II <br />i ownsnlp Kange z)ecxlon <br />NTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring El Soil Sampling/Characterization <br />El Public Water System <br />If different from Owner: W@ter System Name Contact Name or ono Number <br />I YPE OF WORK ❑ New Well ❑ Replacement Well 11 Well Alteration/Modification Li Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings 11 Geotechnical <br />❑ Out -Of -Service, "all ❑ Out-Of-Selvice Well Renewal EI Cross -Connection Repair <br />r New Pump 'Lmo ReDlacement lel Pump Reoair ��_ 11 Raise Well Casino <br /># of borings <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary [I Auger El 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/Gauge/ASTM Schad ❑ Steel 0 Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-'10 gal water) ❑ Sand Cement sack mix/7 gal water <br />0 Bentonite (20% solids) ❑ Other <br />rrnni• l�laromo I4 MoChnnl M Ri i H n Fro. Fall M(ichor rl Rata rrlant / �rnoloratnr /mmol <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 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 <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] AM IN COMPLIANCE WITH ALL <br />WORKERS COMPEN T ION S. <br />HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE DATE <br />—T <br />D ARTMENT USE ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By I Date �- <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Employee ID# <br />P CIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />W <br />D <br />v <br />v <br />m <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />OSO <br />-7'1 <br />i� i� i� <br />Ir�F'��iv�i <br />EI -ID 43-06 WELL /PUMP PERMIT <br />8/04/08 <br />