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WELL / PUMP PERMIT <br /> r SAN JOAQUIN COUNTY ENVIRONMENTAL HEArm L-.ARTMENT 304 E WEBER—E 3R°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> j `2— A)- 6 H- Lt.,)1 N rn <br /> F JOB ADDRESS ] <br /> CROSS SFREET APN_.1_d I,1`30-37 PARCEL SIZE I AND USE APPLICATION# Y"rT 05- <br /> OWNER NAME r L L �-77 � g `� ✓ <br /> ^�?2— <br /> +� / r PHONE 2-, f� " / <br /> Sr/ <br /> OWNER ADDRESS CJ� (/�J�/�/ L�11 CITYISTATEIZIP f.�A y�J� <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 0 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private X116gation/Agricultural Q Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ydifferent from owner: ater ystem anne Conuci%rne or Phone Numr— <br /> TYPEOFWoRK I7 New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Borin s #of borings # f borings <br /> g( ) © o <br /> Geotechnical <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair N <br /> ❑New Pump D Pump Replacement Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Too] ❑Push Point ❑Other { <br /> Proposed Well Depth ft Excavation in diameter ❑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 it ❑Neat Cement(941b bag/5-10 gal water) ❑Sand Cement sack mix 17 gai water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name Q Specs on File ❑Specs Submitted �- <br /> ,Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) p <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensioni:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> I <br /> PUMP ❑Submersible ❑Turbine 13 Other HP Pump Set ft Standing Water Level ft <br /> i <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 /> MI UM 24 HOUR ADVANCE NOTICE RE UIRED FOR INSPECTIONS <br /> TTCLE DATE <br /> i <br /> 1 <br /> _3_ <br /> F B ' <br /> Q41N 1 ON <br /> H <br /> t-I-I- J�. <br /> DEPARTMENT USE ONLY tf f <br /> Application Accepted By - ` �` 2 Date 1-7 Area Employee ID <br /> L � <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date �-- - 11 WAIVER Received <br /> 2 <br /> Constructed Well Depth ft <br /> COMMENTS .SrEI—Vir=E o �r�oEC4rfu,C, <br /> S IBS 0 r lb t''�.r nJ a13 ` <br /> OF- 23 ( I:-A <br /> PE SC Received ( CheeW Amount Date Permit/ Invoice# Well IDN <br /> Codes Info B ash Remitted Service Request# <br /> NZDD <br /> 3 psi S Sv + <br /> EHD 43-02-006 <br /> I127I2005 WELLPUMPPERMIT <br />