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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT "" 600 EAST MAIN STREET-STOCKTON CA 95202 })468-$420 <br /> NON-REFUNDABLE PERMIT CALL 209'. 1697 FOR INSPECTIONS EXPIRES 1 YEAR FRop, A ISSUED <br /> 07 <br /> FC:R:OSSSTREET <br /> SS 13 m '-(�_�} L J�c� • CITY/ZIP �0 -rVA-) m <br /> Q: APN � c�-C7 PARCEL SIZE'� ' LAND USE APPLICATION# <br /> ME ICO u _ T a W v,.� PHONE <br /> DRESS SoCITYISTATEIZIP <br /> R p�V"'� . G-V 55 t.tJ„� `4S {� )� PHONE c� - 3 2- J Z O <br /> R ADDRESS r'• 1-J w i 6 CITY/STATEIZIP 1-aCTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE PL!. -57 ❑C-61 ❑D-09 a Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE ❑DomestidPrivate 0 Irrigation/Agricultural d Industrial r]Water Quality Monitoring El Soil <br /> on <br /> y5 m ame SamplingChat <br /> 11 Public Water System <br /> eum <br /> Ifdifferent from Ower ...... o a ameor I <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification D Other <br /> B Monitoring Wells) #of wells 0 Soil Borings) Nofeonngs p Geotechnical 9o borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> D New Pump ❑Pump Replacement r"ump Repair <br /> WELL CONSTRUCTION - <br /> b <br /> Drilling Method ❑Mud Rotary ❑Air Rotary D Auger ❑Cable Toot ❑Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom [I Gravel Pac JGravel Size in diameter f/} <br /> Ll Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel U Plastic D Stainless Steel D Other <br /> Grout Seal Depth ft D Neat Cement(94 lb b9ry5-10 gat wafer) I]Sand Cement SackmW7 gal water <br /> D Bentonite(24%solids) ❑Other <br /> Grout Placement Method D Pumped ❑ Free Fall El Other ❑Retardant/Accelerator(name) (` <br /> PEDESTAL Installed By D Driller U Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width '� fi Length--!Z- ft Thick�_in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine therlet HP_]_ Pump Set ft Standing WaterLevef ft <br /> I HEREBY CERTIFY THAT f 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. y <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE DATE - b <br /> LL <br /> T #V <br /> E vi <br /> L DPAT E <br /> EPARTMENT U7 E ,ONLY <br /> Application Accepted By Date f f 0 k Area Employee ID# <br /> Grout Inspection B Date ❑ SPECIAL Well Permit <br /> Pump Inspe n B Date ��/�� 0 WAIVER Received <br /> Soil Boring Inspection B Dat Constructed Well Dept $ <br /> COMMENTS <br /> PE SC ReceivedCheck Amount Date Permit/ Invoice# Well IDN <br /> Codes Info B s Remitted Service Re uest# <br /> '¢3 Asa 7111oyj,,jg5 Ll`2 3 <br /> WI 43-06 <br /> 9126!07 WN-L!PUMP PERMIT <br />