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WELL / PUMP PERMIT <br /> SAN OA IN COUNTY ENVIRONMENTAL HEALTH —ARTMENT 304 E WEBEOViot Sen FL-STOCKTON CA 95202 - (209)4618-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ZII ER72 �4 ,C .4 Lz E: CITY/ZIP�S�`o%/ <br /> y a <br /> CROSS STREET t! rd AiC�- J -./-r g <br /> APN aeT^O]O- 'PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME �,` 67�t>Dlf�g>7� �05 a 767 ,�,, ,�,,,,//]] <br /> ( <br /> OWNER ADDRESS A <br /> / ��// NEE Wil/ <br /> fz CT LBG C CITV/STATE/ZIP 7PHONE <br /> CONTRACTOR l <br /> ,y' p� PHONE a 7 cF'T <br /> CONTRACTOR ADDRESS y-yry /Cj CITV/STATE/ZIP <br /> SUBCONTRACTOR <br /> t PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Qualitp Monitoring ❑Soil Sampling/ChamcWn-tion <br /> ❑Public Water System m <br /> If different from Owner eter ystem Neme onmct eme or one um r <br /> TYPE OF WORK ❑New Well ❑Replacement WellW ell Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s)— #of borings dngs <br /> ❑Geotechnical #ofbo <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair . <br /> ❑New Pump ❑Pum R Iacemenl ❑Pump R air <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open0111 ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductorip <br /> Well Casing Diameter _in Thickness/Gauge/ASTM Sched 1 ❑� Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib b -10 ga I., arer) 4t ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer ec ds "i,_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall they ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ ❑Pa tractor Other <br /> 3rconcmte Pedes imensio i�th (f Length "S it Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Vubmersible Turbine ❑ er - FIP Pump Stt R Standing Water Level ft <br /> I HEREBY CERTIFY THAT I VE PREPA THIS OPLICATMON AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINA ES, STATES, ANVV RULES �D REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WIT THE CALIF IA TRACTO STATE LICENSE BOARD AND THAT t AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATIO WS. <br /> IM-k / .ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLEDATE <br /> S <br /> q <br /> T � <br /> DEPAR ' MENT USE ONLY �L`/ <br /> Application Accep B , Date t 2 I �1f1'� Area Employee lD# ` "t l <br /> Grout Inspectio By ❑ SPECIAL Well Permit <br /> Pump Inspection e 5 7 ❑ WAIVER Received <br /> Constructed Well Dep ft <br /> " ! <br /> COMMENTS 4G cfvl Z <br /> 2A-,97o <br /> K. <br /> PE Sc Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> Z o50 JD o li 450 S 5 Z 0 <br /> Into o-02A <br /> la72005 WELL PUMP PERMIT <br />