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/OW) <br />WELL / P1MP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3- FL- STOCKTON CA 95202 - (209) 468-342 <br />1NUIN-REFUNDAB(LEE PERMIT <br />CALL 209 953-7697 rOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />t- <br />J� G LIVE 011,K <br />�,O <br />CITY/ZIP <br />STjChc"la�l C(hSQ�ZIZ <br />CROSS STREET_ <br />pL� <br />/ <br />APN PARCEL SIZE N AL <br />+ <br />LAND USE APPLICATION # <br />OWNERNAME <br />U(S-TeRru-� <br />PHONE <br />PHONE <br />OWNERADDRESS <br />813-1 G L\\/(-- ont.c fZN�) CITY/STATE/ZIP <br />`>"THCry C'A Vi S2tZ <br />CONTRACTOR <br />W, L`("n. Nr -4 C•- <br />PHONE ZO 1 -y" -0")Z <br />CONTRACTOR ADDRESS <br />NN\b �aV Lv <br />t� t� <br />\ �t'y� �`\ CITY/STATE/ZIP <br />l..J-\'j'1. C --As --%-zL 4(j <br />SUBCONTRACTOR <br />PHONE <br />❑ C-57 ❑ C-61 ❑ D-09 ❑ Other A <br />CITY/STATE/ZIP <br />NUMBER S? S \) S" 1 EXPIRATION <br />GEOGRAPHICAL INFORMATION: Coordinates X Y_ _ Townshin Ran— Nertlnn <br />NTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public WaterSystem <br />H different Crom ner. arcr ystem ame ontact ame or one um r <br />I YPL UP wURK U New Wen U Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Wells) # of wells ❑ Soil BorinB() s a orborings 11 Geotechnical s ofborings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pumn ❑ Pumn Renlacement "12(p,— R—;� <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/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 1b bag/5-10 gat 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 />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ftThick in ❑ Christy Boz ❑ Stove Pipe <br />PUMP ❑ Submersible ❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br />I 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. 1 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />TITLE CawNCt <br />SIGNED ��� rr/C5\�IEN� <br />�� I DATE -ZS - �-) <br />Application Accepted By.( <br />Grout Inspection By v <br />Pump Inspection By .� -r <br />Constructed Well Depth <br />COMMENTS /} _ A /QjZZ <br />DTMENT/ SE ONLY <br />at Date f <br />Date <br />ft <br />Area Employee ID#.. <br />❑ SPECIAL Well Permit f <br />❑ WAIVER Received <br />PE SC SC Received Ch <br />Codes Info B Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # Invoice # Well ID# <br />VD 41-02-006 <br />1005 <br />WELL PUMP PERMIT <br />