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i <br /> WELL/PUMP PERMIT <br /> q 'J SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E.Main Street-STOCKTON CA 95202- (209)468-3420 <br /> c+. NON-REFUNDABLE PERMIT CALL. 209 953-7697 FOR 1NsPEcTiONS EXPIRES I YEAR FROM DATE ISSUED <br /> 9L�(��y�� <br /> JOB ADDRESS l ��r!- ��� CITY(L � <br /> • ' 'O+J e <br /> CROSS STREET V I' /, ]I API PARCELSaE s LAND USE APPLICATION N <br /> OWNER NAME I�7yl s PHONE <br /> OWNER ADDRESS CITY/STATE/LIP <br /> CONTRACTOR GVC��GD/�'�I S, KM W7rf M /sem <br /> �`r�h' Rt�ICe-'r R p'3 <br /> Jr)�I � Ir.. PHONE Z -r o/� <br /> CONTRACTOR ADDRESS CITY/STATF/ILIP rMtAlf C.Aw <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS ��....// CRY/STAATE(Lup <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 16ther 11' a t o NUMBER—74V-3-1— EXPIRATION DATE_ / B-7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> tr,TENPED UsE ❑Domestic/Private ❑ImgatiordAgricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> Cl Public Water System <br /> If dg—,f—0— e1er Y.— .— untnct artlC Or C uT <br /> b. <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> a of <br /> ❑Monitoring Well(s)_#ofwells ❑Soil Boring(s) bD"Dsy 13 Geotechnical s of bDrings <br /> ❑Out-OfService Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pum2 ❑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 Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 IA bag/5-/0 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 O Pumped ❑Free Fall ❑Other Cl Retardant/Accelerator(name) <br /> PFDESTAI. Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width R Length A Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ILSubmersible ❑Turbine ❑Other j IIP /jQ Pump Set ft Standing Water Level fi <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.-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 COM ATION LAWS. <br /> MIN MUM 24 110I!1 IWANCENOTWERE, UIRELI FOR INSPECTIONS <br /> SIGNED TITLE l/t Tech DATE b-7 <br /> 1 <br /> N O �i ��1► <br /> EVA ` <br /> y <br /> OR MENT 4UE N Y <br /> Application Ac Date Area Employee IDN <br /> t Inspection B <br /> Date ❑ SPECIAL Well Permit <br /> ump Inspection B <br /> Date ❑ WAIVERReceived <br /> Com epth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ Invoice 00 Well IDN <br /> Date Se ice Re uest# <br /> C Info B Cash emitted , <br /> wt:u.Ivr,>P relturr <br />