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OA QUIN COUNTY ENVIRONMENTAL HEALTH D`r RWELL / PUMP PERMITNT ... <br /> 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL( 9)953-7697 FOR INSPE TIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 02PZf� �' E lam/ _y <br /> JOB ADDRESS �/ <br /> CITY/ZIP <br /> � �H <br /> CROSS STREET OctOctAPN+ <br /> PARCEL SIZE ©t LAND USE APPLICATION# p <br /> OWNER NAME <br /> PHONIzO1 3 J <br /> o� m <br /> �J y <br /> OWNER ADDRESS <br /> CITY/STATE/ZIP <br /> CONTRACTOR �' it <br /> ^ �/�� PHONE ; <br /> CONTRACTOR ADDRESS ( (/� , CITY/STATE/ZIP <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS <br /> CITY/STATE/ZIP <br /> LICENSE -57 ❑C-61 ❑D-09 ❑Other <br /> NUMBER _ EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> Township Range Section <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characteriration <br /> ❑Public Water System <br /> If different from Owner: ater yslem ame <br /> ontact Name or Phone Number <br /> TYPE OF WORK - !ew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Borin s #of borings #of bgorin s <br /> g( ) ❑Geotechnical <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pu--p ❑Pump Re lacement ❑Pump Repair ❑Cross-Connection Repair --5. <br /> WELL CONSTRUCTIO <br /> Drilling Method �Zud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ZZo ft Excavation �� in diameter ❑Open Bottom 'Gravel Pack/Gravel Size n diameter <br /> ❑Conductor asing in diameter / Conductor CCa7sing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 1 (a <br /> ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb hag/S-10 gal wafer) O Sand Cement <br /> Back mix/7 gal water <br /> �ntonite(20%solids) ❑Manufacturer Spec%solids �1/o Name ❑Specs on File ❑Specs Submitted <br /> LPEDE:ST�AL <br /> ut Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> Installed By ❑Driller �i ump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other lip Pump Set ft Standing Water Level ft <br /> 1 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. 1 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 /> /'�Iy�,�� MIN NIUM 24 HOUR ADVANCE NOTICE RE44UIRED FOR INSPECTIONS <br /> SIGNED f)l (- , , (.(�}G fNt' � l� DATE <br /> TITLE <br /> + l <br /> 4C <br /> D- <br /> -41 <br /> 7 = I <br /> --------------L�L, ----- <br />