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LL / Pu IT <br />`k 0C Ci I <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AV - FL- STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT C.AI.L (lU9) Ys-/bY / FOR INSPEC 110NN L' RrIKL' 3 1 T LAK VKUM uAI e, „Sulu <br />JOB ADDRESS ' (Cl "' vr_ f f^` C Crry/ZIP L( ` <br />CROSS STREET er APNv dOU✓_W(PARCEL SIZE LAND USE A <br />PPWATIO�N /# <br />OWNER NAME /-OK/IV(-'C)10,P01"01_t:n PHONE <br />CITY/STATE/ZIPOWNFRADURESS li _ � <br />CONTRACTOR )5;Qce A SrI 7-E'. A5S4r_44_1 /ITS) PHONE -_161? <br />— 77 <br />ry <br />CONTRACTOR ADDRESS VAL-1-Cy 1115 11 ( A V CITY/STATE/ZIP b117M01"D <br />®C� `%f �l✓ 5 <br />SUBCONTRACTOR lfij PHONE} (°9 ® e Z <br />SUBCONTRACTOR ADDRESS �~)t"> s V/" r LCA S /��L �•! ®r CITY/STATE/ZIP j)j4A4()A1,Q 'N,i ` ! ®'t r! /` .' <br />ILICENSE XC -57 ❑ C-61 ❑ D-09 ❑ Other <br />NUMBER EXPIRATION DATE IZ3rl'200 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 'O�New Well ❑ Replacement Well ❑ Well Alteration/Modification Other oy7fgT 4-c— <br />• <br /># of borings # of borings <br />❑ Monitoring Weil(s) # of wells ❑ Soil Boring(s) ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary it Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 20-5 `6 ti 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 "7a ❑ Steel astic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth / G ft ❑ Neat Cement (94 lb bag 15-10 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 />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft 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 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />/ MUM 2 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED / TITLE DATE <br />DATE �✓ ! c�t�S <br />Application Accepted By++v-C\ <br />DEPARTMEN21(.10<— SE ONLY <br />Date <br />Grout Inspection By Date <br />Pump Inspection Bdb Date <br />Constructed Well Depth <br />COMMENTS <br />ft <br />Area Employee ID# © -t t! <br />Q SPECIAL Well Permit <br />❑ WAIVER Received <br />PE SC ReceivedC <br />Codes Info, B <br />ec <br />ash <br />Amount <br />Remitted <br />D e Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />EHD 43-02-006 �{ [!, ,,, WELL PUMP PERMIT <br />U2712005 <br />