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y <br /> r) <br /> WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT, 304 E WEBER AVE 3"n FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> i <br /> Al <br /> CITYIZIP <br /> 'CJ <br /> JOB ADDRESS 1 9 —1 1(0 <br /> -33 <br /> APN � [ PARCEL SIZE <br /> CROSS STREET f+ 'd <br /> PI{ONE <br /> OWNERNAME �' <br /> CITYISTATE/ZIP ^' <br /> OWNERADDRESS F M ; <br /> t PHONE <br /> CONTRACTOR 7 <br /> CITYISTATEIZIP G" (31 <br /> CONTRACTOR ADDRESS <br /> PHONE <br /> SUBCONTRACTOR <br /> CITY/STATEIZIP <br /> SUBCONTRACTOR ADDRESS OL <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 Nrother <br /> NUMBER EXPIRATION DATE �I <br /> Township Range Section <br />- -' 'GEOGRAPHICAL INFORMATION! Coordinates X <br /> INTENDED USE J �l mestic/Private 13Irrigation/Agricultural [I Industrial [I Water Quality Monitoring [3 Soil SamplinglCharacterization <br /> ❑Public Water System ater ystem ame ontacr ame or one in r <br /> If different from Owner: <br /> TYPE OF WORK 0 New Well Q Replacement Well ❑Well Alteration/Modification number Test <br /> rinysle ❑Other number ofborings <br /> ❑Geotechnical <br /> number of wells 0 Soil Boring(s) <br /> ❑Monitoring Well(s) <br /> ❑Out-Of-Service WeIV ❑Out-Of-Service Well Renewal <br /> ❑Well Destruction <br /> F1 CrossConnection Repair <br /> elacement ❑Pum Repair <br /> ❑New Pu <br /> WELL CONSTRUCTION ❑Cable Toot/ ❑Push Point ❑Other <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger, <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack!Gravel Size in diameter <br /> ❑Conductor Casing <br /> in diameter / Conductor Casing Depth ft <br /> ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Well Casing Diameter . . in Thickness/Gauge/ASTM Sched�, sack mix/7 gal water <br /> Grout Seal Depth ft ❑Neat Cement(941h hag/5-10 gal wafer} ❑Sand Cement ❑Specs on File ❑Specs Submitted E <br /> ❑Bentonite(20%solids) [IManufacturer Spec%solids % Name <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed m ❑Driller [3 Pump Other Pump Contractor in ❑Christy Box ❑Stove Pipe <br /> ❑Concrete Pedestal Dimensions: Width ft .Length ick tt <br /> HP Pump Set ft Standing <br /> PUMP bmersible ❑Turbine ❑Other Water Level V r <br /> ❑Open Bottom ❑Gravel Pack ❑Uncased [3 Other WELL DESTRUCTION ft <br /> tt Depth to Water ft ❑Casing to be Perforated from ft to <br /> Well Diameter in Total Depth <br /> suck mix 17 gal water ❑ <br /> Sealing Material ' ❑Neat Cement(94 lb hag/5-10 gal wafer) ❑Sand Cement ❑ Bentonite Pell <br /> File ❑Specs Submitted <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name <br /> Placement Method ❑Pumped ❑Free Fall ❑Other ❑Com fete to Existing Surface Pad <br /> I <br /> 13 Complete with Mushroom Cap ft below grade P <br /> I HEREBY CERTIFY THAT l HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAIS <br /> N <br /> tEQUIREDJOAQUIN COUNTY ORDINANCES, STATE LAWS, <br /> CONTRACTORS AND RULES CERTIFY THAT My f <br /> TATE LICENSE BOARD REGULATIONS. I A AND THAT I AM IN COMPLIANCELWI H ALL <br /> CURRENT AND ACTIVE WITH THE CALL <br /> WORKERS COMPEN TION LAWS. <br /> 'f NIMUM 24 HOUR ADVANCE NOTICE R IR D FOR INSPECTIONS <br /> TITLE DATE <br /> i <br /> SIGNED <br /> I ! <br /> j I <br /> 6 VIR Nh'I NTA.HE-: LTH DM INr <br /> i <br />