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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY E\vIRONMENTAL HEALTH DEPARTMENT 31)4 E WEBER AYE 3N0 FL-STOCKTONCA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> L it <br /> u' CrrYIZIP A �o' r7 _ <br /> T- a <br /> CROSS STREET=; �7 C <br /> . APV •} `— ���=P RCF.L7 S1ZE�,LA7Vp USE APPLICATION# <br /> WAIIOWNER NAME <br /> PHO\E <br /> OWNERADDRFSS Ct'rk'/STATE/ZIP_ �] <br /> CONTRACTOR � <z <br /> CONTRA(TORADDRESS ✓„/ j� !j) � a 4 CITYISTATFJZIP <br /> SUBCONTRACTOR L-�1 PHONE <br /> SUBCONTRACTOR ADDRESS _ CITY/STATE/ZIP <br /> LICL*7SE 01�57 ❑C-til ❑D-09 ❑Other_ NUMB ft' 1%P l{`' � EXPIRATION DATE <br /> GEOGRAPHICAL INFOR-MATION: Coordinates X Y f►� <br /> _ Township Renge Section <br /> INTENDED USE DRublic is Private ❑itTigationlAgricultural ❑Industnal ❑Water Quality Monitoring 1-J Soil Sampling/Characterization <br /> ❑Public Water System <br /> [fdiReremfromO,urs ? Ater yseem, arse .o�nu�t�arnn:x one um s <br /> TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(S)_4 of welLs ❑Soil Borings) a orfOf"c' d of bone <br /> gs_ <br /> Q Out-0 U Geotechnical <br /> Out-0f--Service Wcll ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> eW Pump ❑Rump R laseraent ❑Pump Repair <br /> WELL,CONSTRUCTION <br /> Drllling Method Q Mud Rota ❑Air Rotary 7 Auger �blc Tool ❑Push Point ❑Other <br /> Proposed Well Depth R Excavation_ in diameterpen Bottom C3 Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing fktpth t; <br /> Well,Casing Diameter S�_ in Thickness/GaugeASTM Schell ❑Steel ❑Plastic 13 Stainless Steel ❑Other <br /> Grout Seal Depth 40 <br /> "� R ❑Neat eat Cement(94 r,h bag/5-10Kair 1 water) d Sand Cement sack m /7 gal water i <br /> ❑Benionite(20"/a so—lids) ❑Manufacturer Spec solids % Name _ ❑Spas on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> EDERT Initalled By 11er ❑Pump Contractor�❑ Other <br /> �6�concrete Pedestal Dimensions:Width—,Length 'tl Thick in ❑Christy Box ❑Stove Pipe <br /> UMC Submersible 13 Turbine ❑Other HP: Pump Set ft Standing Water Level <br /> I HEREBY CERTIFY AT I RAVE PREPARED THIS APPLICATION IND TKAT 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.W'IT11-ALL <br /> WORKERS COMPENSATION LAWS. <br /> M1 M 24 HOUR ADVANCE NOTICE R`,:QLIIRF;D FOR INSPECTIONS <br /> S1C:NED T40 ial <br /> r <br /> Ile- <br /> A N E <br /> I{ E <br /> -----------i <br /> 6— <br /> DEPART N T USE \ L Y <br /> Application Accepted w Datef Area_ Employee 11 <br /> Grout Inspection By _ Da lc_ ��/��/Qy C1 SPECIAL Well Permit (( <br /> Pump Inspection Fy `�' Date ���� El WAIVER Received <br /> Constructed Well Depth fl <br /> :OMMENTS / <br /> PE SC Reeelved Che Amount Permit/ <br /> Codes info —By Cash Remitted Dale Service Request 1) Involee N Well IDN <br /> t)tgZI <br /> SIZO 05 2-3 C 10 <br /> 4C1 O 2 6 Di'i <br /> a,,a:„� <br />