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1o1 �� WELL/PUMP PERMIT <br /> USAN aICWUOIN COUNTY ENVIRONMENTAL HEALTH L ARTMENT 600 EAST MAIC. _-rREET-STOCKTON CA 95202 - (209)468~3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> y <br /> JOB ADDRESS Y I r- P—e) CITYIZIP 3 m <br /> ff CROSS STREET APN O �l f C' `1 7 PARCEL SIZE • LAND USE APPLICATION m <br /> OWNER NAME72- � l h ' r' ,:I r j PHONE �' y <br /> OWNER ADDRESS tij'e A� NI <br /> l� CITYISTATEIZIP <br /> CONTRACTOR X411 ^ PHONES 3y- 'L L ,'-5, <br /> CONTRACTOR ADDRESS CITYISTATEIZIP L.xlw1 J/ 0tzl <br /> alcl <br /> SUBCONTRACTOR PHONE7_� <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP . <br /> LICENSE ,,kZ-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER r 9 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial u 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 >iew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of parings <br /> ❑ ut-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross connection Repair <br /> ew Pump ❑ Pump Replacement G Pump Repair <br /> WELL CONSTRUCTION -- <br /> Drilling Method)r<Mud Rotary ❑ Air Rotary ❑ Auger o%El Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth_ft Excavation 1; L in diameter ❑ Open Bottom14ravel Pack/Gravel Size in diameter Imo, <br /> ❑ Conductor Casing in diameter 1 Conductor Casing Depth ft 1 <br /> I <br /> Well Casing Diameter-6--in Thickness/Gauge/ASTM Schad ' ❑ Steel Plastic ❑ Stainless Steel ❑ Other 1' <br /> Grout Seal Depth ft ❑ Neat Cement(94 ib bag/5-10 gal water) A§and Cement sack mix17 gal water <br /> ❑ Bentonite(20%Solids) ❑ Other <br /> Grout Placement Method).Pumped ❑ Free Fall ❑ Other u Retardant I Accelerator(name) <br /> PEDESTAL Installed By riller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width - _ft Length ft Thick in 11 Christy Box ❑ Stove Pipe , <br /> PuMP ✓u: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 <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS 1j1 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALLi <br /> WORKERS COMPENSATION LAWS. <br /> fflINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> '¢j _ <br /> rff <br /> LELC <br /> ILL <br /> l ,r <br /> ,.t. <br /> ev <br /> Irl ire N <br /> DEPARTMENT USE: ONLY � <br /> Application Accepted By Date Area Employee ID# S SII (`f r <br /> Grout inspectio date J ❑ SPECIAL Well Permit <br /> Pump inspection Data ❑ WAIVER Received <br /> Soil Baring Inspection By _Date Constructed Wgll Depth ft <br /> COMMENTS - _ :' <br /> PE SC Received heck Amount Permit/ <br /> Codes Info B ash Remitted Date Service Re uest# Invoice# Well ID# <br /> _ 77 <br /> �__. . <br /> ✓lf�:J / 'L�(�'LG'' '�'�' 'Are, - WELL/PUMP PERMIT <br />