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' 3151 <br /> WELL/PUMP PERMIT. ,.; Cl-:�ZZS• GSI <br /> .SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-$TOCKTON CA 95202-(209)488-I <br /> 3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESLn <br /> S <br /> _ CIN/ZIP m <br /> CROSS STREET APN �c]-t;j p_ �/ PARCEL SIZE_)3. .LAND USE APPLICATION# <br /> OWNER NAME H <br /> PHONE <br /> •�OWNER ADDRESS CITY/STATE/ZIP <br /> rr_ ^_` p <br /> CONTRACTOR tcr1A � �[„ PHONE I(20A) gj-/3L�) <br /> CONTRACTOR ADDRESS 2-C`L>1 <br /> r?"- AtOOrr N Sit `.v rJ CITY/STATE/ZIP <br /> 1 5�.,,>v, , c.4 9 s-2 0 6 <br /> SUBCONTRACTOR 7-1V141 1 11D r,`'I ii n5 /PHONE WOO-7�fq- 02 b) <br /> SUBCONTRACTOR ADDRESS PMS, �nx JNA$ CITY/STATE/ZIP L,,,d,, /S-236 <br /> LICENSE )(C-57 C-61 ❑D-09 E)Other NUMBER & 35014 ExPIRATIONDATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE 0 Domestic/Pnvate : Irrigation/Agricultural 0 Industrial D Water Quality Monitoring XSoil Sampling/Characterization <br /> D Public Water System <br /> M differem from Owner: - ys m ame <br /> TYPE OF WORK 0 New Well D Replacement Well D Well Alteration/Modification Other <br /> --Monitoring Well(s) #of wells 0 Soil Borin s9O ' <br /> Forbonngs <br /> Geotechnical <br /> D Out-Of-Service Well ❑Out-Of-Service Well Renewal I Cross-Connection Repair <br /> 0 New Pum - Pump Replacement 0 Pump Repair <br /> WELL CONSTRUCTION - <br /> Drilling Method j Mud Rotary D Air Rotary n Auger D Cable Tool D Push Pant f I Other <br /> Proposed Well Depth IT ft Excavation 6- In diameter D Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched D Steel D Plastic u Stainless Steel C Other <br /> Grout Seal Depth ft D Neat Cement(94 fb 4ag/540/ga/water) o Sand Cement sack-mixn gal water <br /> ❑ Bentonite(20%solids) >CiDther 14de Qt'A / 5,1v r`F " Gro.nj&.,&4e- <br /> Grout Placement Method 0 Pumped J Free Fall D Other G Retardant/ ccelerator(name) <br /> PEDESTAL Installed By 0 Driller D Pump Contractor n Other <br /> D Concrete Pedestal Dimensions:Width ft Length R Thick in 0 Christy Box D Stove Pipe <br /> PUMP D Submersible Turbine D 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 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE �-fAr'f- OP,0(01)�Zf DATE 1—5—oy <br /> I <br /> �R r <br /> O <br /> Y <br /> = t g <br /> _ or I NiQi,[IiY <br /> O METIT L <br /> s <br /> ,A,l <br /> ENT <br /> =MENT IUSE OPtLY <br /> Application Accepted By Date Area Employee IC#G'`�Z / <br /> Grout Inspection By Date _ -` '_I SPECIAL Well Permit <br /> Pump Inspection By Date --. WAIVER Received <br /> Soil Boring Inspe ion B Date 9��� � Constructed Well Depth K <br /> COMMENTS <br /> PE SC Received Check#! Amount Perm'U <br /> Codes Info B as Remitted Data Service Re uest# Invoice# WeIIID# <br />