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WEL1tr7P PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AvE 3"FL-STOCKTON CA 95: 466-3420 <br /> NON-REFUNDABLE PEEr�RMIT /��// CALL 209 955=169'7 FOR INSPECTIONS JEXPIRES 1 YEAR FROM L...E ISSUED <br /> JOB ADDRESS 2`^` ^�/ - + �t1�45� CITYIZIP r—ool 6� ' ?S d 4 y <br /> CROSS STREET �y�` / / S <br /> /iu /4 G/!�/� PARCEL SIZE_.,., LAND USE APPLICATION#�7 <br /> 1 OWNER NAME PHONE <br /> OwNERADDREss 00, 90)c 46S _ CITYIS7'ATEIZIP L4491 <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CrrYISTATEIZIP <br /> 1 SUBCONTRACTOR PHONE <br /> t SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE mesticlPrivale ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> [r dsttemnr fmm Own am yslrm ame _ Contact Nmc oe rwteN..D. <br /> TYPE OF WORK ❑New Well Q Replacement Well ❑Well AltemtionlModification ❑Other <br /> a of boringi <br /> 13 Monitoring Wells) #of wells ❑Sail Boring(s) M of horiagi ❑Geotechnical <br /> )(Out-O&Service Wel 8�� ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method. ❑Mud Rotary ❑Air Rotary Cl Auger ❑Cable Tool ❑Push Paint ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottum ❑Gravel Pack I Gravel Sim in diameter <br /> 0 Conductor Casing in diameter I Conductor Casing Depth It <br /> Well Casing Diameter in ThicknesslGaugelASTM Schell ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/3-10 gal water) ❑Sand Cement sack mix 17 gal water <br /> ❑ii.entonite(200/6 solids) ❑Manufacturer Spec%solids % Name I C7 Specs on File ❑Specs Submitted <br /> Grant Placement Method ❑Pumped ❑Free Fall ❑Other .. ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ntractor ❑ Other <br /> ❑Concrete Pedestal DpKinsJonc 3kidth ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Cl Submersible ❑Tu ne ❑ er HP Pump Set ft Standing Water bevel R <br /> I HEREBY CERTIFY THAT 1 HAVE AEP RED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES S A LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE 41FOR74IA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> NI UM 24 H R ADVANCBLjP E REQUIRED FOR INSPECTIO <br /> SIGNED TITLE `✓/ DATE <br /> F <br /> I JO O,AN CC U <br /> AL <br /> t <br /> -- •--`.._ -. - -. DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID##G 7 r L <br /> Grout Inspection B Date ❑ SPECIAL Well Perinit <br /> Pump Inspec on By Date ❑ WAIVER Received <br /> Construct I Depth <br /> COMMENTS <br /> PESC Received hec Amount Date Permitl nvaice# 'Well ID# <br /> Codes ;Info B ash Remitted Service Re ueat# <br /> 216",/ <br /> EHD43-02006 WELL PUMP PERMIT <br /> MTnOe5 - <br />