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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL-HEA LTH-DEPARTM ENT 304 E WEBER AVE 3M0 FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT o {/s CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED S <br /> JOB ADDRESS ! /✓��`� I r"C'f�I✓ �Y'"� CITY/ZIP <br /> CROSS STREET <br /> IC APN OS 1—I/O/ <br /> ,r L PARCEL SIZE LAND USE APPLICATION q � <br /> OWNER NAME C�u t N 3 O 4 PHONE✓67—366? <br /> OWNER ADDRESS ,T f/ CITY/STATF/ZIP <br /> CONTRACTOR �4�,///1 t71,�/�(� rib r PHONE3�4�Y2 <br /> CONTRACTOR ADDRESS (T d 4J�7" s / CITY/STATE/ZIP. 6�X//h&'AL n <br /> SUBCONTRACTOR PHONE (�l <br /> SUBCONTRACTOR ADDRESS 77CITY/STATTyE�fs/ZIP Q <br /> LICENSE <X-57 13 C-61 11 D-09 ❑Other NUMBER) ExPIRATION DATE C �� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE mestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ir diRcrenr from Owner. Water ysrem eme omacr ame or Phor,, um r <br /> TYPE OF WORKS New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Wells) M Of wells ❑Soil Boring(s) x of bonngs ❑Geotechnical s otbonnas `� <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair (((� <br /> ',17New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION (M� <br /> Drilling Method><Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other y' <br /> Proposed Well Depthh.R Excavation in diameter ❑Open Bottom <Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth <br /> ft <br /> Well Casing Diameter 4 in Thickness/Gauge/ASTM Sched L DZ:' . ❑Steel--6{"Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth AX�' —R ❑Neat Cement(94/b bug/5-/0 gal wafer) Sand Cement/O sack mix/7 gal water <br /> ❑Bentonite(201/solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> I Grout Placement Method -NQPumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> ` PFDF.STAL Installed By W1ZDri1ICT ❑Pump Contractor ❑ Other <br /> _ - <br /> ❑Concrete Pedestal Dimensions:Width e4 R Length R Thick in ❑Christy Box ❑Stove Pipe <br /> ! PUMP Submersible ❑Turbine ❑Other HP Pump Set R Standing Water Level R <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. 1 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 /> {(/n IMUM 24 HOUR ADVANCE NOTICE <br /> y/REQUIRED FOR INSPECTIONS 7 <br /> SIGNED -��^'^`/ !"-' TITLE Q VC!/�Ca/ - DATE <br /> J <br /> R C <br /> pR <br /> DEPA TMENT USE ONLY Q� <br /> Application AccepADepth <br /> Date Area Employee IDM <br /> Grout Inspect -GQc Date ❑ SPECIAL Well Permit <br /> l <br /> t Pump InspectDar ❑ WAIVER Received <br /> Constructed Well ft — <br /> r COMMENTS <br /> s <br /> PESC Received c T- Amount Date Permit/ Invoice M Well IDM <br /> Codes Info B Remitted Service acquelt M <br /> tc 83e8 3K o? 671v2 <br /> Sd <br />