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WELL I PUMP PERMIT <br /> 3�°FL-STOCKTON CA 95202 - (209)468-3420 <br /> 304 E WEBER7l0" y <br /> .N JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> RTMENT EXPIRES 1 YEAR FROM DATE ISSUED <br /> CALL(209)953-7697 FOR INSPECTION. � � <br /> ,VON-REFUNDABLE PERMIT I O <br /> CITY/ZIP C <br /> JOB ADDRESS PARCEL SIZE AND USE APPLICATION# <br /> /A_j 7 S APN <br /> CROSS STREET PHONE <br /> OWNER NAME CITY/STATE/ZIP <br /> OWNER ADDRESS PHONE GI <br /> CONTRACTORCITY/STATEIZIP <br /> CONTRACTOR ADDRESS g �. PHONE <br /> SUBCONTRACTOR CITYISTATE/ZIP <br /> SUBCONTRACTOR ADDRESS �_s EXPIRATION DATE <br /> NUMBER <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other Section <br /> - <br /> Y <br /> TownshipRange- <br /> GEOGRAPHICAL INFORMATION: Coordinates X (�Soil Sam lin Characterization <br /> INTENDED USE ❑DomestiC/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring p i� <br /> ❑Public Water System ater ystem ame ontact arae or one um r <br /> If different from Owner: <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other #of borings <br /> of <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) ❑Geotechnical_; <br /> ❑Out-Of-Service Well ❑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 DkAuger ❑Cable Tool ❑Push Point ❑Other (J <br /> Proposed Well Depth_ ft Excavation Q7 in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> rJ <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other till <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10gal water) ❑Sand Ce ent sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Nam SQ t Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe G <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> OARD AND THAT 1 AM [N COMPLIANCE WITH ALL <br /> WORKERS COMP NSATION LAWS. 1 <br /> INIM HOUR ADVANCE NOTICE REQUR FOR INSPECTIONS <br /> SIGNED <br /> TITLE � DATE <br /> v <br /> I\ E <br /> 0 LJ F <br /> A J Q IN C FM <br /> `DEPARTMENT USE ONLY HF-ALTHDEPARTMENTApplication Accepted By (off <br /> Date_ ] Area Employee ID# <br /> Pump Inspection By Date 7 3 7 1 <br /> Grout Inspection B �-=i=_� Date i <br /> y��' ❑ SPECIAL Well Permit Constructed Well Depth ft 13 WAIVER Received <br /> COMMENTS <br /> PE SC Received hec Amount <br /> Codes Info CashDate Permit/ <br /> Service Re uest# <br /> emitted Invoice# Well ID# <br /> q3-7.,- t s 13 3 3-1 <br /> S 7j0 C)j) 5 <br /> EHD 43-02-006 <br /> 1/2m005 <br /> WELL PUMP PERMIT <br />