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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"D Ft.-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS G CITY/GIP CROSS STREET / APN .PARCEL SIZE Z,�f LLAND USE APPLICATION# OWNER:NAME / PHONE OWNER ADDRESS �� — �� CITY/STATE/ZIP CONTRACTOR PHONE: ' /__ { CONTRACTOR ADDRESS �L�(7k �J.�J CITY/STATE/ZIP " / SUBCONTRACTOR /s�'^ / AL1 / �t PHONE: - J c� � SCBCONTRAC`FORADDRESS CITY/STATE/ZIP LICENSE -57 -61 ❑D-09 ❑Other NUMBER A EXPIRATION DATE. GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE rnestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sam pling/Charlcterization ❑Public Water System _ If different from Owner —W5ei5vsternAame tact Name or Phone Number er TN PE OF WORN DMew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other _ ❑Monitoring Well(s) q of wells ❑Soil Boring(s) a of borings ❑Geotechnical „ofbormgs ❑Well Destruction ❑Out-Of-Service Well O Out-Of-Service Well Renewal ew Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCT ON Drilling Method ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other_ Proposed Well Depth—f fl Excavation 17— in diameter ❑Open Bottom 1471ravel Pack/Gravel Size % io diameter r ❑Conductor Casing in diameter / Conductor Casing Depth _ fi � �• Well Casing Diameter —140,in Thickness/Gauge/ASTM Sched i%A/W) ❑steel -j6mastic ❑Stainless Steel ❑Other Grout Seal Depth�() tl ❑Neat Cement(94 lb ba .,S-10ged w rr r) ❑Sand Cement lurk mir i 7 gal Water r• Aentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement/Method C3 Pumped ❑Prre Fall ❑Other ❑Retardant i Accelerator(name) PEDESTAL Installed By ❑Driller O Pump Contractor --Other ❑Concrete Pedestal Dimensions: Width ti Length_11 Thick in ❑Christy Box ❑Stove Pipe P1 Nip ubmersible ❑Turbine ❑Other HP Pump Set ti Standing Water Level ft r I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERSCKEN N'ON S.UIb1 24 HOUR ADVANCE NOTICE: RIRED FOR INISPECTIONS ILISIGNED TITLE ��' �� — DATE I I It I I 111 1111 . 1 1 I T L TH HDIE AI[TWENr 10 DEPARTMENT USE ONLY" Application Accepted By z Date '/ / 7 C' Area j Employee ID# P Y C� �� / C Grout Inspection B Date ` ❑ SPECIAL Well Permit Pump Inspection By_� Date 7 ❑ WAIVER Received Destruction Inspection By Da tc Constructed Well Depth rt COMMENTS C t [ c lam? " rL, /r.(r all / [: /r.,Cy / �.y� rim 'T�e ca�E'lI PE SC Recei ed CC_heec Amount Permit/ Codes Info By ash emitted Date Service Request q Invoice# Well ID# Lit 4:� Iry '� Lzs� EHD 43-02-006 WEI.I.PUMP PERMIT xW04