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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 95202-(209)468-3020 <br /> NON-REFUNDABLEPERMIT <br /> /� oeyCALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOBADDRESS 41, 3 ZL. e 6'e /Je-?'" X� �ITY/ZIP / Q fic4„( <br /> • CROSS STREET i4LfN,r 7/I .�/APN V O�r'1 b� O BARCEL SIZE=LAND USE APPLICATION# <br /> OwNERNAMEj .r Jp� .Ci z— / PHONE <br /> OWNER ADDRESS.. �/�?. ` . ��r/i'��Ili✓ �N CITY/STATF/ZIP i/Yt �ifH, ! Jy�.,�a <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR - PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE [3Domestic/Private gation/Agriculturul ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterizadon <br /> ❑Public Water SyySS <br /> Vdiff—,fro. e. Ww y.— ertw C..wt aloe or Ph.. a <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other 1�' <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) s of bonnga ❑Geotechnical s ofbo..S. N <br /> ❑Out-Of--Service Well ❑Out-0S-Service Well Renewal Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other (� <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter f 1, <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submittal <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 Cl Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 /> b J/ <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNEDT /I AC /y TITLE �'� -�'-W DATE <br /> i <br /> VR <br /> lit-JL jU P T AE1 <br /> D ARTMENT USE/ ONVY <br /> Application epted By to 3 �r AreayT �— Employee ID <br /> Grow Inspection By Date a//ac»� ❑ SPECIAL Well Permit <br /> Pum Inspectiqn.By Date ❑ WAIVER Received <br /> Constructed Well Depth it <br /> COMMENTS <br /> — ;,.,.:0�=4,,, La <br /> • PE SC Received cheeldy, Amount Dam Permlt/ Invoice Well ID# <br /> Codes Info B Remitted Service Request# # <br /> OS N� G to oS <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 127/2005 <br />