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I 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 PERMIT CALL 20 953-7697 FOR INSPECTIONS EXPIRES YYEAR FROM DATE ISSUED <br /> y <br /> JOB ADDRESS CrrY/Z!P <br /> a <br /> 0 <br /> CROSS STREET J APN -D ARCEL SIZE •/ LAND USE APPLICATION# <br /> OWNER NAME PHONE <br /> OWNER ADDRESS N�•A I� CITY/STATE/ZIP /' ! •� <br /> CONTRACTOR -do PHONE <br /> 1 <br /> CONTRACTOR ADDRESS2-1:2 dd OL CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrrY/STATEIZIP <br /> iLICENSE 41C-57 aC-61 ❑D-09 ❑Other NUMBER3-22,0v ExPIRA71oN DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private rrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If differentfrom Owner: Water Systm Nam C.nmt Nam or Ph.. u ' <br /> TYPE OF WORK ❑New Well O Replacement Well ❑Well Alteration/Modification O Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(.) p of baring. O Geotechnical sof borings <br /> O Out-Of-Service Well O Out-Of-Scrvice Well Renewal O Cross-Connection Repair I <br /> O New Pump O Pump Replacement Pump Repair <br /> WELL CONSTRUCTION ' <br /> Drilling Method O Mud Rotary O Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter O Open Bottom O Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gouge/ASTM Sched ❑Steel O Plastic ❑Stainless Steel ❑,Other <br /> Grout Seal Depth It O Neat Cement(941b bag/5-10 got wafer) O Sand Cement sack mix 17 gal water <br /> ❑Bentonite(201%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File O Specs Submitted <br /> Grout Placement Method ❑Pumped O Free Fall ❑Other ❑Retardant/Accelerator(name) i <br /> t, PEDESTAL Installed By ❑Driller O Pump Contractor ❑ Other i <br /> O Concrete Pedestal Dimensions:Width ft Length ft Thick in O Christy Box ❑Stove Pipe <br /> I <br /> UMP ❑Submersible j urbine O Other HP Pump Set It Standing Water Level tt <br /> j 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 /> i CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS C TION LAWS. {If <br /> MIN! 2 OUR ADVANCE NOTICE$EQQUIRED FOR INSPECTIONS <br /> SIGNED TITLEat N <br /> s%FF�C DATE <br /> -70 <br /> I <br /> .1 2hni <br /> I S <br /> N OL N74e ff, <br /> H E I <br /> 1 <br /> lL D `A 1'MENT - �1S'E LY Q <br /> Application Accepted By�=,aa—a AWA Iff Date ` Area Employee 1D# <br /> r <br /> Grout InspectionBy Date O SPECIAL Well Permit <br /> i <br /> Pump Inspection G�-' Date Gp_L� ❑ WAIVER Received i <br /> Constructed Well Dept' 1 •y�tt-- `..,, �L'' I� <br /> COMMENTS .4ar4�- '44-6 A <br /> PE SC Received h Amount PermiU <br /> Codes Info B Cash Remitted Date Service R uest# Invoice# Well[D# I <br /> I <br />