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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 - (209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS _ EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS ! I 0// cRYIZIP �-!a 1 r"✓ s• ` m <br /> / _ v <br /> CROSS STREET _ I c Q -y C -/` �/���L APN D PARCEL SIZE�" > 1(LAND USE APPLICATION# ` ion <br /> OWNER NAME �il Z PHONE ��✓ J O V (�D '�n' <br /> OWNER ADDRESS CrrY/STATE/ZIP ___ q- -2 <br /> CONTRACTOR �� �+ PHOONEM , -> L �� <br /> CONTRACTOR ADDRESS_ -_� CITY/STATE2 /I <br /> 1P 6--`1029 0 � <br /> SUBCONTRACTOR -_ _-_ _ PHONE <br /> SUBCONTRACTOR ADDRESS _ _ CITY/STA`T�E///ZZIIPP <br /> 2✓" <br /> ,LICENSE a-57 C-61 _. D-09 Other _ NUMBER12 _ EXPIRATiONDATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE �Lbomestielprivats Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System ,_ <br /> If blit nl from Owner r systemName --�,oTacClName or re Number <br /> TYPE OF WORK><New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells #of wells Soil Boring(s) #or oonrgs Geotechnical a or bon gs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> _ ''d4New Pump ___PumQReplacement _Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method-ClIDlud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth"Z)a"' ft Excavation 11- in diameter Open Bottom yc.Gravei PaddGravel Size in diameter <br /> Conductor Casing _ in diameter / Conductor &sing Depth _ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched _--- Steel -._Plastic Stainie s Steel Other <br /> Grout Seat Depth-2 00 ft Neat Cement(94 lb bagi5-10 gal water) 11;and Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Methoda<Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Conto : Other <br /> Vac <br /> _ Concrete Pedestal Dimensions:Width ft Length ft Thick in _Christy Box = Stove Pipe <br /> CPUMP ►Submersible Turbine . Other HP Pump Set ft Standing Water Level ft <br /> -- _ -_____ —__—_ <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 /> MI IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED /1 N`'l.A✓ ,� TITLE ll W F/� DATE <br /> IL <br /> LA <br /> 64 L <br /> E T P R _j <br /> _ DEPARTMENT USE ONLY <br /> Area EmployeelD# <br /> _.i� <br /> Application Accepted _ Date-� L A �--- <br /> Grout Inspection y Date S __ SPECIAL Well Permit <br /> Pump Inspection Date _ WAIVER Received <br /> Sal Boring Ins on B Date_ Constructed Well Depth ft I <br /> COMMENTS c <br /> PE SC Received ec Amount Date Permit/ Invoice# Well ID# <br /> Codes Into B Cash RemittService Request 0 _. <br />