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1' <br /> WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3R°FL-STOCKTON CA 95202 - (209)458-3420 <br /> i NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED y <br /> i` � <br /> 3 P5 ��G/�� F CITYIZIP r <br /> JOB AD SS CI A A <br /> APN <br /> Q Y P RC£L SIZE [.J LAND USE APPLICATION# M5 to <br /> CROSS STREET _ <br /> OWNER NAME v <br />{ OWNER ADDRESS Itf� I / TATVZIP <br /> I l � ave ep . e W l rae �' <br /> DiC r L PHONrE� <br /> CONTRACTOR s� . 66 y�u a ud Qr lI I <br /> CONTRACTOR ADDRESS CJ� I rL7l 1 1 L�T�I t I J <br /> PHONE <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS ,CITYISTATE/ZIP <br /> LICENSE I9 C-J 1 13C-61 13D-09 ❑Other NUMBER Y`t7EXPIRATION DATE .�Q <br /> GEOGRAPHICAL INFO TION: Coordinates X Y Township Range Section <br /> INTENDED NE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil SamplinglCharacterization <br /> h ❑Public Water System <br /> p, if different from wner. water system Name ontact ame or one um Cr <br /> TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other p of borings <br /> p of borings ❑Geotechnical <br /> ❑Monitoring Well(s) #of wells [3 Soil Boring(s) <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump R lacement ❑Pump Repair <br /> WELL CONSTRUCT_IONN <br /> Drilling Method Mud Rotary 13Air Rotary ❑Auger ❑Cable Tool ❑Push Point C1 Other <br /> ❑ <br /> Proposed Well Depth�Q _ft Excavation /I diameter ❑Open Bottom ET Gravel Pack I Gravel Size [�in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> I Well Casing Diameter -16—in Thickness/Gauge/ASTM Sched_/60 El Steel ] oc ❑Stainless Steel ❑Other 1 <br /> } Grout Seat Depth /00 R 0 Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water <br /> ®Bentonite(20% lids) ❑Manufacturer Spec%solids % Name l G L � eMppees on File ❑Specs Submitted <br /> Grout Placement Method umped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Erpump Contractor ❑ Other r p� <br /> ❑Concrete Pedestal Dimcnslons:Width ft Length fl Thick in ❑Christy Box ❑Stove Pipe V <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 L�F1 <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS S' <br /> f CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> -WORKERS COMPENS TION LAWS. <br /> 1 IMUM 24 HOUR ADVANCE NOTICE QUI R INSPECTIONS �J <br /> SIGNED TITLE DATE �T <br /> 1 <br /> LT I <br /> all <br /> C <br /> P 1 <br /> 1 <br /> G L1 <br /> 1Ft N N <br /> H <br /> r <br /> 4•. _ �. .. . "":, t°"�' ' ap P.A'RTMENT 5E NLY <br /> .. :�-+rte-. --- <br /> f Application Accepted By Date~ _ A,(-'a' Employee Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth tt <br /> ' 11 <br /> COMMENTS /� v v <br /> i <br /> PE SC Received 11e& ount er <br /> Date Pmit/ Invoice# Well IDN <br /> i Codes Info B ash Remitted Service R uest# <br /> WELL PUMP PERMIT <br /> EHD 43-02-006 .--- <br /> yll2772005 <br />