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WELL/PUMP PERMIT (n 130q.Goya <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 31e FL-STOCKTON CA 95202 -(209)468-3420 Lt <br /> NON-REFUNDABLE PERMIT <br /> CALL 209 953-7697 FOR 1',SPECI IONS /fEXPIRES 11�YEAR <br /> FROM DATE ISSUED <br /> Y /h CITY/ZIPJOBADDRESS ✓ / <br /> >O <br /> CROSS STREET /-Z' (kA <br /> _- _ /�(�I�Q n APN 20� PARCEL SIZE AND USE APPLICATION# <br /> I T-cy 7 <br /> OWNER NAME pio PHONE <br /> OWNER ADDRESS ���� a CITY/STATF/ZIP <br /> CONTRACTOR 'YY IO l�,/1_-_r-�(il�/1�D��T �I�7KC PHONE j' �I� <br /> CONTRACTOR ADDRESS 9 \ 1+�L/l�l jb Cf7Y/ST'ATFJZIP b '(]C L'I J � - T -�jt,r <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATFIZIP <br /> LICENSE IXC-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE / Q � <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Chamcterindon <br /> ❑Public Water System <br /> If diR rem from Own ate, y'um sme Conuct Namw or Phonj N.m <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring WCII(s) #of wells ❑Soil Boring(s) s of boring' ,Geotechnical x of twring' <br /> ❑Out-Of--Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION 1 <br /> Drilling Method ❑Mud Rotary ❑Air Rotary 'Auger ❑Cable Tool ❑Push Paint ❑Other <br /> Proposed Well Depth S7-,2-0 ft Excavation4 112, in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sim 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 ft ❑Neat Cement(94/h Gag 15-10 gal water) ❑Sand 'emcn} sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name lfD!/1� ❑Specs on File ❑Spas Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelera of r fume) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ftThick in ❑Christy Bos ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level It <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. 1 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 <br /> ,FOP <br /> I�N1S\wP,1EnC/T11Y/SNS �n <br /> SIGNED PG i,)'./- TITLE='t'f TT �1 r1V r/J J1"Yye V` DATE tl!/-7106 <br /> l ( <br /> S <br /> 1 1 <br /> „ r <br /> EN <br /> P. <br /> - - D M E N T USE O N L V - --- --- - ---- r5��� <br /> Application Accepted B Datc Area Employee ID# <br /> Grout Inspection B Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedCheck#/ Amount Date Permit/ Invoice# Well IDN <br /> Codes Info By Cask— Remitted Service Request#4M'7- 150 - <br /> °D <br /> 4 20Y9 <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1."!712005 <br />