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WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3a"FL-STOCKTON CA 95202 - (209)465-3420 <br /> .NON-REFUNDABLE PERMIT CALL(209)9S3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ��`T C—IT YIZIP -:;" C4 <br /> JOB ADDRESS �U �lJ[�r� s' 5 d <br /> CROSS STREET ti l/��t�t'� APN; -30~.`9 1�PARCEL SIZE BLAND USE APPLICATION# y <br /> v <br /> + � � PHONE <br /> OWNER NAME ( �(/�b ! „ <br /> CITVISTATEIZIP �'}-� <br /> OWNER ADDRESS <br /> PHONE S I <br /> CONTRACTOR. '�99 (,/ <br /> CONTRACTOR ADDRESS <br /> UZ S f CITVISTATEIZIP 64 <br /> PHONE <br /> SUBCONTRACTOR f +k <br /> r <br /> CITVISTATEIZIP <br /> SUBCONTRACTOR ADDRESS <br /> LICENSE C-57 ❑C-6l ❑D-09 ❑Other - <br /> NUMBER (/O EXPIRATION DATE 0& oj� <br /> Y Township Range Section <br /> GEOGRAPHICAL INFORMATION: Coordinates X <br /> INTENDED USE '❑Domestic/Private ❑lrrigationlAgricultural 13 Industrial ❑Water Quality Monitoring Soil Sampiing/Characterization <br /> .. , <br /> 1.❑Public Water System ater ystem ame tacjam,,or one um er <br /> If different from Owner:TYPE OF WORK ❑New Well O Replacement Wel] ❑Wel]AlterationlModificati n r E.,.. ,e t h of borings <br /> a of borings �„" r,y r,� ❑Geotechnical <br /> ❑Monitoring Well(s) #afwells oil Boring(s} 4__ �} rT�� {� <br /> t ❑Well Destruction" ; M Out-of-Service Well Peru 1-4ut�C7l1 esivtC��efe ��r�� without <br /> i, <br /> ❑New Pump ❑Pump Replacement ❑Pum 'Re air, WD <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger s ❑Cable ToolyCi9� fli : , I� <br /> Proposed Well Depth jd/L ft Excavation_{tin diameter . ' ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> k ❑Conductor Casing in diameter 1. Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Scbed ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> 1 Grout Seal Depth ft . ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name So tl S ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name` <br /> E PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stave Pipe <br /> Pump ❑Submersible ❑Turbine ❑Other ` ' HP Pump Set ft Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other ft <br /> in T D Dep be rfor <br /> S in Materi ❑ t t(94 g/ 10 gal ter) ❑S d Cement ack a 17 ga ate Benton Pe is <br /> e(201 o ) Ma facture cc%solids Name ❑ e ub ted <br /> Pia ent Metho ❑ p Fre all ❑Other <br /> omplete It ush In ft below gra o Tete to Existi Su ce Pad <br /> 1 HEREBY CERTIFY THAT l HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> r 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 ANDyTHAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> NIMUM 24 HOUR ADVANCE NOTICE <br /> ,41/�RRE.QUU[RED FOR INSPECTIONS <br /> SIGNED <br /> TITTLE f( i DATE 2- 0/6' <br /> e° <br /> ✓ , <br /> jwe <br /> � <br /> 'Lt r" EE 1 <br /> 26 <br /> Y E _ <br /> JQ <br /> 49 <br /> ;D PARTMENT- S ;ONiY <br /> Application Accepted B Date Area Employee ID# <br /> le <br /> Grout inspection By EF- Date - - ❑ SPECIAL Well Permit <br /> Pump Inspection By Date © WAIVER Received <br /> Destruction Inspection By <br /> Date Constructed Well Depth ft <br /> COMMENTS <br /> I <br /> PE SC Received heek#1 Amount Date Permit! Invoice# Well ID# <br /> Codes Info By. Remitted Service Re uest# <br /> U-0 - <br /> MASTER WATER WELL PERMIT <br /> EHD 43-02-006 - <br /> 12122f2003 <br />