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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH + ARTMENT 344 E WEBn 3N°FL-STOCKTON l I4U <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> CITYIZIP �- f� <br /> �y �.�7{y ^'7 ,4 <br /> �7 '^'� <br /> CROSS STREET U V1�• _A tJOf��� O�/ PAif�E 3 ZE LAND USE APPLICATION i�� <br /> OWNER NAME PHONE969 <br /> e t zQo y�"9/Q v <br /> 3�z 6 <br /> OWNER ADDRESS C[TYISTATEIZIP <br /> CONTRACTOR 9L r PHONE <br /> CONTRACTOR ADDRESS CTTYISTATEIZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP .; <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 [I Other NUMBER EXPIRATION DA <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private 'gation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization 0 <br /> ❑Public Water System <br /> If different from Owner: Water System Name onlact ame or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Wells) #of wells ❑Soil Boring(s) #of boring C3 Geotechnical of borings <br /> >140t-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair r <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack I Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth R ❑Neat Cement(94 lb bag 15-10 gal water) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length R Thick in ❑Christy Box ❑Stove Pipe <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 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 /> MINIMUM 24 HOUR TI ADVANCE NOTICE O CE REQUIRED FOR INSPECTIONS <br /> SIGNED a /Zw4fwepJ. TITLE ...... _ - DATE <br /> 15 t .._� <br /> , <br /> 9- <br /> r i M <br /> O PN o <br /> e µ N r L <br /> JILL <br /> a�w <br /> .n <br /> f <br /> = — <br /> DEPARTMENT USE ONLY <br /> Application Are _ "r✓` Date/��� Area Employee 1D ��� <br /> Grout Inspection Date ❑ SPECIAL Well Permit <br /> Pump Inspecti B Da �� ❑ WAIVER Received <br /> Constructed WeIICDepth ft <br /> COMMENTS <br /> O <br /> PE SC Received Check#1 Amount Date Permit/ Invoice# Well ID# <br /> Codes info -BY Cash Remitted Service Request# <br /> EI2D 43-02-006 <br /> 1/2712065 / � � WELL PUMP PERMIT <br /> - ~rte <br />