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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DL_..ATMENT 600 EAST MAIN _ .REET-STOCKTON CA 95202 - (209)4684420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> y / T <br /> JOB ADDRESS CITYIZIP S� C�Gt— m <br /> 2 C� v <br /> CROSS STREET _ � �t APN nZ I, —����C7)PARCEL SIZE f LAND USE APPLICATION# m <br /> _ OWNER NAME �✓ !` !� PHONE ! /G�J <br /> OWNER ADDRESS b S ' �Z.J CITYISTATEIZIP7C� <br /> -/� <br /> CONTRACTOR P <br /> 2-:3 V /d !L <br /> "-�` �.S ��C - F f� HONE_n�[i ! <br /> CONTRACTOR ADDRESS �ll I� -_ CITYISTATEIZIP C. <br /> SUBCONTRACTOR PHONE <br /> i <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 ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Wafte`r­System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well D Replacement Well ❑ Well Alteration/Modification D Other <br /> #of borings #of borings <br /> ❑ Monitoring Well(s). #of wells ❑ Soil Boring(s) ❑ Geotechnical <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump ❑ Pump Replacement ❑ Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling'Method D 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 <br /> ❑ Conductor Casing in diameter I 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(94 Ib bag/5-10 gal water) ❑ Sand Cement sack..mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> D Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> uMP 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 REQUIREQ' 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 /> MINIMUM R� VANCE NOTICE REQUIRED FOR-INSPECTIONS <br /> 7 SIGNED TITLE D � N� /C�-- DATE rz. !3 .-e <br /> k <br /> f <br /> I AO <br /> V <br /> 0 <br /> 0OL IN a N <br /> 71 <br /> L <br /> DEP A R MENT U5 O LY <br /> Application Accepted Date :77 l Area Employee ID# <br /> Grout Inspection By Date—]. El SPECIAL Well Permit <br /> Pump Inspection By Date © WAIVER Received <br />'L Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit) Invoice# Well!D# <br /> Codes Info By cash Remitted Service Request# <br /> " 3oS�s )-2/r3Jo SRoo 5 Zq3 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> i 9!28!07 <br />