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( 3�7 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCNTON CA 95202-(209)4W3420NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 1 ;j;j <br /> CITr/LPCROSS STREET WFS7" �PARCEL SIZE � LAND USE APPLICATION#OWNER NAME �/ PHONEOWNER ADDRESS UCITY/STATE/ZIP <br /> CONTRACTOR C © -PHONE&& / !21 ,J-_a_ <br /> 1 CONTRACTOR ADDRESS CITY/STATFJZIP L(�--i <br /> SUBCONTRACTOR / - <br /> I' SUBCONTRACTOR ADDRESS CrrY/STATFJZIP PHONE <br /> LICENSE -57 G C-61 O D-09 11Other NUMBER 4—W21eq EXPIRATION DATE v L. <br /> GEOGRAPHICAL INFOR ATION: Coordinates X Y Township_ Range Section_ <br /> INTENOEp USE mestirJPdvafe DIrrigationlAgricultural ❑Industrial ��Water Quality Monitoring a Shc Sampling/CharaCterizetion <br /> LI Public Waters= <br /> ( II di1r0rerrt from O.vner, r ys m eme <br /> ems or ne um r <br /> TYPE OF WORK V<ew Well G Replacement Well D.Well Alteration/Modification U Other <br /> U Monitoring Wells) #of wells ❑Soil Boring(S) n of bora g, C Geotechnical 0 or borings <br /> C Out-Of-Service Well U Out-0f-Service Well Renewal U Cross-Connection Repair <br /> U New Pump U Pump Replacement U Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION - `N. <br /> Drilling Method AMW Rotary U Air Rotary U Auger a Cable Tool U Push Point U Other <br /> Proposed Well Depth ft In diameter <br /> �_ Excavation�_ peen Bottom Gravel Pack/Gravel Size SX/G <br /> C in diameter (/l <br /> Conductor Casing In diameter / Conductor Casing Depth ft W <br /> Well Casing Diameter_Cin Thickness/Gauge/ASTM Sched (10 C Steel v astic U Stainless Steel C Other <br /> Grout Seal Depth 1Q jL ft C Neat Cement(941b bagi5-10 gal water) U Sand Cement <br /> sack mix/7 gal water <br /> P<entn,t. ❑Other -- <br /> Grout Placement Method ]1 Pumped C Free Fall U Other U Retardant/Accelerator(name) <br /> PEDESTAL Installed By U Driller IiIi Contractor U Other <br /> U Concrete Pedestal Dimensions:Width ft Length ft Thick 'in 7 Chrlety Box U Stove Pipe <br /> PUMP U SubmersibleU Turbine C Other HP Pum Set <br /> P h Standing Water Level ft <br /> WORK WILL BE D <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THEONE 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 2 <br /> WORKERS COMPENSATI N LAWS. <br /> MI 4 OUR ANCE NOTICE REQUIRED FOR IN CTIOO ,q_PLEASE CALL(209)953-7697 <br /> SIGNED <br /> TITLE DATE O <br /> f <br /> i <br /> CFrY <br /> / _ A U <br /> M. v <br /> - I . <br /> L A <br /> A. <br /> `1! Jr -r <br /> t <br /> 5- <br /> Application Accepted 8 Date _ Area 5 . ru <br /> Employee ID# 04 c[� <br /> Grout Inspection B Date l 2d/ U SPECIAL Well Permit <br /> Pump Inspection By Date U WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS WELL- S Alor [.J F[_aarj P[jj-r, ) tt <br /> Y. <br /> PE SC <br /> Received ---;;trhecmount APermit/ <br /> Codes Info B Date Remitted Service Rec3u&st# I voice 9 Well ION <br /> 4a6G t e� S S -#3�f1. i <br /> OD'3�{(� <br /> EHD 4300 <br /> 0 2809 <br /> WELL/PUMP PERMIT <br />