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l L_. WELL / PUMP PERMIT Iu <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH .iRTMENT 304 E WEBEK fE 3"n FL-STOCKTON <br /> NON-REFUNDABLE PERMIT CALL 209 953-7097 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �j /� CITYIZIP /U/ 5^ <br /> CROSS STREET �,v� J L2- _pA1�CE�SIZE LAND USE APPLICATION <br /> C i <br /> OWNER NAME �,4�t�c y �f2t��T_,_.� lr-r PHONE //�� w ✓ <br /> OWNER ADDRESS AM Ivo /86 CITYISTATEIZIP Bell , ZcrO 3SZL-� <br /> CONTRACTOR L F PHONE <br /> CONTRACTOR ADDRESS CITYISTATEIZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER Exri DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township ange . Section <br /> INTENDED USE ❑Domestic/Privaterigation/Agricultural 13]ndustrial 13 Water Quality Monitoring ❑Soi i liiglG zation <br /> ❑Public Water System <br /> If different from wner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring( )5 #of borings ❑Geotechnical #of borings <br /> '>Qut-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump 17 Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter E7 Open Bottom ❑Gravel Pack/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 Ib bag i5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) 11 Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant J Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED a TITLE DATE 2-9-7-476 <br /> �r <br /> N T <br /> Q Al Q <br /> Hl L <br /> DEPARTMENT USE ONLY <br /> Application Ace '.��` �� Date���� Area Employee IDa ��� } <br /> Grout inspection Date ❑ SPECIAL Well Permit <br /> Pump inspecti B l Da ���QL� ❑ WAIVER Received <br /> Constructed Well,Depth ft <br /> COMMENTS 4:'�-7 (j <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> E HD 43-02-006 � � .0 -i / /—��l'' �JC-e �� � WELL PUMP PERMIT ! <br /> 1/27/2005 <br />