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WELL / PUMP PERMIT <br /> PlA3A,f FL-STOCKTON CA 952OZ - (2O9)468-3424 <br /> SAN JOAQUIN COUNTY ENVIRONbtENTAL HEALTH DEPARTMENT 304 E WEBE <br /> NON-REFUNDABLE PERMIT CALL 204 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> / / H <br /> / / �-1 � CITY/ZIPsFg- �z�� a <br /> m <br /> Job ADDRESS _ ry/� �i1 � <br /> V <br /> CROSS STREET �►dl f APN/0, —t�� O_PARCEL SIZE ._LAND USE APPLICATION# V <br /> A <br /> OWNER NAME K?t'--- -1 — r — ;r— L PHONu rr!np" L. L. Cowl IE <br /> OWNER ADDRESS �1 WL- CITYISTATEIZIP r� <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS _ � r �� '��S-— CITY/STATE/ZTP ](�✓�c_ s�0 �� <br /> PHONE <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE t> <br /> GEOGRAPHICAL INFORMATION: Coordinates JCC Y Township Range Section <br /> INTENDED USE ^jDomesticMrivate ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil SamplinglCharacterization <br /> ❑Public Water System <br /> Idifferent from Owner: aler ystem ame ontact ame or one <br /> f um er <br /> (� <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other vim` <br /> V <br /> ❑Monitoring Well(s) #of wells 11 Soil Boring(s) a of borings ❑Geotechnical #of borings <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> Mew Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection 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 1 Gravel Size in diameter <br /> ❑Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter in ThicknesslGaugc/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941h hag/5-10gal water) ❑Sand Cement suck mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ' ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor P Other ✓ <br /> oncrele Pedestal Dimensions- Width a= ft Length ft Thick in ❑Christy Box ❑Stove'Pipe <br /> PUMP A Submersible ❑Turbine ❑Other HP_,,I- 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMU HOUR ADVANCE NOTICE RF.4*IRED FOR INSPECTIONS <br /> SIGNED TITLE, �) DATE <br /> 1 <br /> FA <br /> J <br /> f ,Ido. <br /> rl <br /> S <br /> '� 11 <br /> DEP R T—M _.T--�5 E 'NL <br /> Application Accepted By D t Area Employee ID# �-/ <br /> t Grout Inspection By^ Date ❑ SPECIAL Well Permit <br /> I Pump inspection B Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#1 Amount Date Permit/ Invoice# Well iD# <br /> Codes Into By Cash Remitted Service Request# <br /> a <br /> END 43-02-006 WELL PUMP PERMIT <br /> H16104 <br />