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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 - (209)46$-3420 <br /> NON-REFUNDABLE PERMIT CALL 249 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ui <br /> JOB ADDRESS <br /> clTYIzIP <br /> O'LAND <br /> r3 <br /> CROSS STREET / (,��S �� APN PARCEL SIZE .z I O LAND 115E APPLICATION# rn <br /> 9 PHONE z-� q <br /> OWNER NAME / <br /> OWNER ADDRESS " 5~ � CITY/STATE/ZIP <br /> CONTRACTOR G f� 1_L f PHONE <br /> CONTRACTOR ADDRESS—L-1 I ''' Its 1 CITYISTATE/ZIP (`iiF�S r G <br /> f <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 -I D-09 Other NUMBER EXPIRATION DATE 24Q4 c� <br /> GEOGRAPHICAL INFORMATION: Coordinates XY Township Range Section <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agriculturat Industrial i 1 Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 5 Public Water System <br /> If different from Owner a er ys em Name on a ame or ne Number <br /> TYPE OF WORK?<New Well Replacement Well ❑ Well Alteration/Modification Other <br /> #of borings #of borings <br /> _! Monitoring Well(s) #of wells Li Soil Boring(s) G Geotechnical <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump _= Pump Replacement ❑ Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method *-Mud Rotary Air Rotary Auger ❑ Cable Tool Push Point Other <br /> Proposed Well Depth �ft Excavation 12— 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 2f/ e9 Steel Mastic Cl Stainless Steel ❑ Other <br /> Grout Seal Depth/04�ft - Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Kpumped := Free Fal! 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 C Other HP Pump Set ft Standing Water Level ff <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> /jj ` /rMII,/IN�iIMUMy�;2�4 HOUR ADVANCE NOTICE REgUIRED FOR INSPECTIONS �y ^� <br /> SIGNED_ L1t L !/[a"�e /,p n{ TITLE �i^f ��✓° DATE a!"" f`Z <br /> II �'�/ _ '� .L <br /> T - I <br /> 3 <br /> } <br /> p N <br /> ,, z J lti <br /> v L ti <br /> r ✓ 4 4j <br /> c <br /> TF 9 — I I I I [ I I I I L I I I I <br /> EP R T M E N T U S E O N L Y - q <br /> Application Accepted B Date Area Employee ID# �! <br /> Grout Inspection By �� .a Date l LlSPECIAL Well Permit / <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Che Amount Date Permit] Invoice# Well ID# <br /> Codes Into B Cash Remitted Service Request# <br /> 7, 2-- �d" 713 00 53 <br /> EHD 43-06 WELL iPUMP PERMIT <br /> 8!04108 <br />