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� U <br /> f' /� WELL / PUMP PERMIT _y �� Q -QQ 1 <br /> IN JOAQUIN COUNTY ENVIRONMENTAL HE 1:­ <br /> 304 E WEBI,�SCP-. <br /> E 3"FL-STOCKTON CA 95202 - (209)46$-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> it � <br /> JOB ADDRESS s �~ .1 <br /> CITYIZIP_ � Ct-f J4 T3 <br /> CROSSSTREET <br /> APN 7 ,� C <br /> _� l.�/+-� PARCEL SIZ£. AND USE APPLICATION# 70 <br /> 1 OWNER NAME S w <br /> PHONE <br /> OWNER ADDRESS CITYISTATEIZIP <br /> f <br /> CONTRACTOR <br /> PHONE 4T r1 <br /> CONTRACTOR ADDRESS _ CITY/STATE/ZIP <br /> s <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE C-57 ❑C-61 D D-09 ❑Other � NUMBER XPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ' #of borings #of rings <br /> [3 Monitoring Well(s) #of wells ❑Soil Boring(s) ,eotechnical <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> [3 New Pump ❑Pump R lacement ❑Pum 'Re air <br /> WELL CONSTRUCTION <br /> Drilling Method ❑MRotary Air Rotary Auger ii ❑Cable Tool ❑Push Point ❑Other n <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 I ©Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941h 6aj 15-10 gat water) C]Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name', l%n -L m 4 ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped 0 Free Fall ❑Other ❑Retardant/Accelerator na e) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor s❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP 0 Submersible ❑Turbine ❑Other »HP Pump Set ft Standing Water Level <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE I—L-� ��✓DATE; Q <br /> Irk <br /> k <br /> fi <br /> r: 221 <br /> A J A <br /> 1 R N A <br /> DEPARTMENT USE ONLY =- rc S <br /> Application Accepted By Date Area Employee ID# T U <br /> Grout Inspection By ate 6 % Q SPECIAL Well Permit <br /> Pump Inspection By Date 13WAIVER Received. <br /> Constructed Well Depth ft <br /> COMMENTS �.-•-s <br /> ii <br /> PE SC Received `Checldl! Amount ' Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash emitted + Service Re uest# t <br /> 3� rsv <br /> 1,311 1 3 s�• 71 S 1�7 <br /> EHD 43-02-006 - ""'� 'i WELL PUMP PERMIT <br /> 1/2712005 fi - - ;••:i <br />