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eo <br /> WELL/ PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE <br /> PERMIT <br /> / CALL 209 953-7697 rOR INSPECTIONS EXPIRES <br /> I�YY�-E-,AR F/ROM DATE ISSUED <br /> l"1 ✓p , 1 L^rn pj� CITY/ZIP�I f 1 f�7�-! / -/ / > <br /> JOB ADDRESS m <br /> D <br /> X �A <br /> CROSS STREET I Ki f I _ APNJ V - ✓ / PARCEL SIZE LAND USE APPLICATION# c' <br /> OWNER NAME 21 <br /> J / PHONE <br /> OWNER ADDRESS /✓" �` <br /> GCITY/STATVZIP <br /> CONTRACTOR U. LJ✓f (�PVHOL/NlE� e �fry <br /> ATE/ZIP ADDRESS 1L1G5LI-�aQt/ <br /> y <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP �J(�[7 <br /> LICENSE C-57 ❑C-61 ❑D-09 Other NUMBER EXPIRATION DATE ' V V <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization l" <br /> Public Water System <br /> If differem from Owner Water System Name onuci.ame or one N—b,, <br /> TYPE OF WORK rew Well 11 Replacement Well ❑Well Alteralion/Modification ❑Other <br /> s Monitoring Well(s)_#of wells ❑Soil Bonng(s) x dim,rimp ❑Geotechnical x ofborinQs <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 Cl Mud Rotary ❑Air Rotary ❑Auger Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth .:?`y ft Excavation r.meter ❑Open Bottom ❑Gravel Pack/Gravel Size indiameter <br /> ❑Conductor ng in diameter / Conducor angtCDepth ft <br /> Well Casing Diameter Thickness/Gauge/ASTM Sched_ feel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth I ') ft ❑Neat Cement(94 lb bug/5-10 gal water) )!-S.vxind Cement 4e , Z— sack mix/7 gal water <br /> ❑Bentonite((2/20%solids) ❑Manufacturer Spec%solids % Name 0 Specs on File ❑Specs Submitted <br /> Grout Placement Method ;;KP mped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP bmersible ❑Turbine ❑Other HP Pump Sct=iLSLj.tl Standing Water Level gft <br /> I HEREBY CERTIFY THAT 1 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 /> NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED _ ___ E �— DATE—jg <br /> I <br /> Z 011 <br /> IS <br /> d <br /> f o v r+ <br /> �+ <br /> E '11E <br /> - - D <br /> li A ENT U LE .�N,e L�-f Y q I <br /> Application Accept Date 6 �'�`�� Area Employee ID# <br /> Grout Insp •tion By Date 0 SPECIAL Well Permit <br /> Pump Inspec y Date a�aC�� 0 WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS G / jrtw4iL 3r 5A�e- 5r <br /> PESC Received Ch MI Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Remitted Service Request# <br /> E& `r 0 ISS.ao %V D 0 Z S7 <br /> W <br />