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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Avc 3"O Ft.-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> L�Q/� [-/ 1_ � <br /> JOB ADDRESS F t & ✓.�/1y 'Z c _ CITY/ZIP <br /> /� O <br /> CROSS STREET !e'>'MYK'�S APN - ��-2-3 PARCEL SIZE 31-y b LAND USE APPLICATION# <br /> OWNER NAME 4RNy7 �D p�C-/7/Y`�7 PHONE <br /> OWNERADDRESS _�/ CITY/STATEIZIP <br /> CONTRACTOR a~ 'J� PH �///ONE /S ;S <br /> CONTRACTOR ADDRESS /✓/��1 e `/ ` Ve t CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/SSTATEJZIP �i ? <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 they G(j !!2r NUMBER 7 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural -16k=ustrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner, Wawr Syme. —e ComaI Nameor Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) #ofweils ❑Soil Boring(s) #ofbonnp ❑Geotechnical N ofborinp <br /> ❑Well Destruction - <br /> y ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pum m/ R lacement ❑Pum Repair O Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth 11 Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sizein diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft 9> <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth It ❑Neat Cement(94 lb hag/S-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) . <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length_tl Thick in ❑Christy Boz ❑Stove Pipe n <br /> PUMPNoubmersible ❑Turbine ❑Other HP 7 Pump Set g !&2-R Standing Water Level R <br /> 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS J <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> NIMUNI 24 HOUR ADVANCE NOTIC RRsE, UIRED FOR INSPECTIONS <br /> SIGNED A$6z TITLE�LX+ DATE -�S <br /> 1 <br /> � r_ <br /> 0 <br /> Cut <br /> I S E <br /> ftt##1 1+ <br /> J� T D <br /> r/^An/, I �, <br /> 1, PARTMENT USE ONLY a <br /> Application Accepted By -`Y. Date qlklo Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> mp Inspec <br /> Pution By Date 10-` - ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well IDN <br /> Codes Info B Cash Remitted Service Request p <br /> y.3.litr oso �fZZ So.ot� os (zG0 ( 53 <br />