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SAN JOAQUIN COUNTY ENVIRONMENTAL / PUMP PERMIT <br /> ENVIRONMENTAL HEALT WELL <br /> � 304 WE <br /> Bt.wE 3s°FL-STOCKTON CA 95202 - (209)468-7420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �h5yl / ,U/u [ �JLA <br /> JOB ADDRESS / (/r/ CITY/ZIP (a Li <br /> ��.�} / a <br /> CROSS STREET �-,� ApNQ�7 /O <br /> } � PARCEL IZ LAND USE APPLICATION# <br /> OWNERNAME (� 1_!(,(IyJ L�+ -5utn — // '' <br /> •' J! PHONE c <br /> OWNER ADDRESS ✓ CITY/STATE/ZI"z"/,S C''o(a, /'r-sC / ra <br /> CONTRACTOR , t/l C PHONE <br /> CONTRACTOR ADDRESS U (/L( fes/ ti- CITY/STATE/ZIP 1--e(r `x'`1 <br /> SUBCONTRACTOR PHONE v�7 ' <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/Agriculturel ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ifdiff..tfrom Owner: amr ystem eme ..tact ame.r ne u r <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Wells) #of wells ❑Soil Boring(s) #ofborinp ❑Geotechnical a of borings <br /> IllibutOfService Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> [3 New Pump ❑Pump Replacement ❑Pump 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/Gravel Sin in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Sim] ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped O Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe C�\� <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level R v\1 <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 1 AM IN COMPLIANCE WITH ALL Xf� <br /> WORKERS COMPENSATION LAWS. <br /> INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLEr,V�J DATE <br /> \l <br /> V <br /> UI <br /> A J O II UNTY <br /> AL <br /> -p R ENT <br /> D E P ARTMENTT USE ONLY <br /> Application Acce By Date`-� /�,� Area �1 Employee ID# <br /> Grout Inspection By Date ElSPECIAL Well Permit <br /> Pump Inspection By IX <br /> Date S ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMEN <br /> V <br /> PE SC Received Check#/ Amount Date Permit/ <br /> Codes In-foo B as- Remitted Service Re Best# Invoice# Well ID# <br /> EHD 4J-02-0 <br /> 1amN5 WELL PUMP PERMIT <br />