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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMEN r-At1'IEA-ETH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> I v�D ` �'� L. I/r� CITYIZIP m <br /> JOB ADDRESS > <br /> CROSS STREET APN O­'�1—1/O' v PARCEL SIZE —5 LAND USE APPLICATION <br /> OWNER NAME d`�-P �J 6-J PHONE✓v ' _ v J y <br /> OWNERADDRESS (/�',ks E. j CITY/STATE/ZIP <br /> I <br /> CONTRACTOR X��nH�\�J,Rao:S� � J.all�J PHONE3 34-y-2 IS' <br /> CONTRACTOR ADDRESS L� 0J1,/ CITY/STATL/ZIP tWL n <br /> SUBCONTRACTOR PHONE (\I <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 1:1C-61 ❑D-09 ❑Other NUMBE♦132 3`�� EXPIRATION DATE <br /> GEOGRA PHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE >9'Domestic/Private ❑Irrigation/Agricultural ❑Industrial O Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Namte Contact ame or Phone Number <br /> TYPE OF WORK>C�New Well ❑Replacement Well ❑Well AlterationlModification ❑Other <br /> ❑Monitoring Well(s) #ofwells ❑Soil Boring(s) aofborings ❑Geotechnical Nofborinas <br /> ❑Out-O(-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ^� <br /> ew Pump ❑Rump Replacement ❑Pump Repair lJ <br /> WELL CONSTRUCTION �yyy1 <br /> Drilling Methc d>ZtMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth-3 ft Excavation in diameter ❑Open Bottom <Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter C in Thickness/Gauge/ASTM Sched 7—DO . ❑Steel.Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth_/0 ft ❑Neat Cement(94 lh b9g 1 S-l0 gal water) Sand Cement/0­�' sock mtx/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids—% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method >42'Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> I PEDESTAL. Installed By ><Wriller ❑Pump Contractor ❑ Other - <br /> r ❑Concrete Pedestal Dimensions:Width ft Length fl Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level fl <br /> 1 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 <br /> WORKERS COMPENSATION LAWS. <br /> 1�1 IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE nc jl �./ DATE �` �-�` <br /> D <br /> kA <br /> r <br /> J <br /> RLX.1C <br /> Ut A L <br /> DEPA TMatNT USE ,ONLY <br /> Application Accepted Date� _�j, /�•T� Area Employee ID# <br /> Grout Inspection B -lac Date////�i�lYT7 ❑ SPECIAL Well Permit <br /> Pump Inspect' n By Datc�aG�C7 ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> it <br /> COMMENTS t%4 _lr <br /> PE SC Received c Amount Date Permit/ Invoice# Well ID# <br /> Codes Info H Remitted Service R e nest# <br /> K cc07b 2 <br /> 0 <br />