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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 6W4RTMENT 304E WEBER1A 3-FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT /�/ CALL 209 9C53-7697 FOR INSPECTIONS �EJX�PIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESSCI -�J. wv 99 JI ��V Crry/ZIP L%7 ! �'] d� D <br /> //fiLnn � nn `J� 0 <br /> CROSS STREEr ,44Q/ D APN 17"!_ D�Z—U 2PARCEL SIZE /- O LAND USE APPLICATION# <br /> 5 t ==^�//t y <br /> OWNER NAME PHONR: <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR / Y / D/ J Ci 1'r N <br /> CONTRACTOR ADDRE � CITYISTATE/ZIP <br /> 1 0 • �� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 Vother NUMBER EXPIRATION DATE 1091 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range_ Section_ <br /> INTENDED USE mestic/Private ❑Irrigation/Agricultuml ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterimtion <br /> ❑Public Water System <br /> IfdUTerent from Owner' ettt perm ame onmct ame or one um r <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #ofbormp ❑Geotechnical #of boanp <br /> ❑Out-Of-Servi Well ❑Out-0f-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum lmp Replacement ❑Plump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth It Excavation in diameter ❑Open Bottom Cl Gravel Pack/Gravel Sin in diameter CAI <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft (� <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other d <br /> Grout Seal Depth R ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other T <br /> ❑Concrete Pedestal Dimensions:Width R Lengthft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP _ mersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level , R Q� <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN �ll� <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 /> IM UM 24 L119PUR ADVANCE NOTICE R QUIRED FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> I -litA J A UI C U <br /> NIR N E A <br /> _ J DEPARTMENT/USE ONLY �-/Z <br /> Application Accepted By / — Date T Z3 d Area Employee ID# -7 37• `k/ <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By DateV//T ❑ WAIVER Received <br /> Constructed Well Depth R <br /> COMMENTS���.F/��z r/7 9n-��9,�v�c®,>taliL <br /> 3 r <br /> PE SC Received bee Amount Permit/ Invoice# Well ID# <br /> Codes Into B ah emitted Date Service Re uest# <br /> 43k1 asat4 i.W SolSo. N LA Z3 b 0 5 d <br /> END 43-02-416 WELL PUMP PERMIT <br /> l WaN5 <br />