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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTR DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202-{209).46&3420 <br /> NON-REFUNDABLE PERMIT CALL(20 )953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> • JOB ADDRESS CITY/ZIP O �'�' > <br /> e� e _ <br /> CROSS STREP.T AIN �StPARCEL 11. LAND USE APPLICATION#� ropi <br /> OWNERNAME PHONE <br /> ��_ I <br /> OWNER ADDRESS © CITYISTATVZIP ���...�. <br /> CONTRACTOR 4,rt ^� <br /> PHONE <br /> � T. � <br /> CONTRACTOR ADDRESS r>1 l� CITY/STATPJZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/Z[P <br /> LICENSE )d C-57 ❑C-61 ❑D-09 ❑Other NUMBER V EXPIRATION DATE <br /> GEOCRAPHICALINPORMATION: Coordinates X Y _ Township Range Section <br /> INTENDED USe mestic/Private ❑Irrigatior/Agricultuml ❑Industrial ❑Water Quality Monitoring Cl Soil Sampling,'Cbaracterization <br /> ❑public Water Svstem <br /> I[ditfaeot hom bwnae; ea:r ysa,m sme '—_''—Conmct a ne um <br /> TYPE OF WORK D New Well ❑Replacement Well ❑Wdl Alteration/Modification ❑Other <br /> O Monitoring Well{s) tl of wells ❑Soil Boring(s) ,r afL n.P ❑Geotechnical M ofbo ng <br /> ❑Ou[-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> cw Putop ❑Pump Replacement ❑Pump Repair <br /> WELLCONSTRUCTIoN <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point O Other _ <br /> Proposed Well Depth ft Excavation in diameter O Open Bottom ❑Gravel Pack/Gravel Size m diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/OaugelASTM Sched ❑Steel ❑Plastic O Stainless Steel ❑Other <br /> Grout Seel Depth ft ❑Neat Cement(941b bag/5-10 gal ware.,) ❑Sand Cement sack mir/7 gal water <br /> ❑Bentonite(20^/solids) ❑Manufhotumr Spcc%sobds_% Name ­ ❑Specs on File ❑Specs Submitted <br /> Grout Plseetttent Method O Pumped ❑Free Pall ❑Other ❑Retardant!Accelerator(name) <br /> ED Installed By ❑Driller ❑Pump Contractor Other <br /> Couerete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box ❑Stove Pipe <br /> ?S!L ubmersible ❑Turbine ❑Other HP Pump Stt tl Standing Water.L-cl.1 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 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAW <br /> 1 UM 24 HOUR ADVANCE NOTICE Q,UUIRE(D FOR INSPECTIONS <br /> SIGNED TITLE ! 5 DATE <br /> I <br /> r <br /> C <br /> tri OE T4T <br /> �A)I.TMENT SE NNLY ^' iJf <br /> Application Aceepted aY � L1i� Date J��t rf" Area Employee]Dii- `'l(J <br /> Grout Inspection BY Date _ �`—'r-- ❑ SPECIAL Well P¢TTriit <br /> Pump Inspection _ Date / /O ❑ WAIVER Received <br /> Constructed Well <br /> D,elpthh D <br /> COMM EN TS�A1T//l�Fi'�S< / �!/f'T '� /�Y.Vi s'-/-,a-0 <br /> PE SC Received Check#/ Amount Permir/ <br /> Codes into B Cash R.-I—A Date Involce# W`R ID# <br /> END 43-02-006 <br /> 1127120OS WELL PUMP PERMIT <br />