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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202-(209)469-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP�N C1 -�On� —\S <br /> (\ O <br /> CROSSSTREET \ \C t1Oc\� ApN PARCEL SIZE • LAND USE APPLICATION II (� 1 •� <br /> OWNER NAME PHONE <br /> OWNER ADDRESS_ . [��'x `O CITY/STATE/ZIP S�Q)Q�L�((a���`ea <br /> CONTRACTOR 1 '` VR\� ��\ PHONE RS\ A %A-S&%q <br /> CONTRACTOR ADDRESS \`�1 �`(��a \1A\\ ` CITY/STATE/ZIP%-\-,Z�10-�ttrent <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS 1A CITY/STATE/ZIP N 1 <br /> LICENSE C-57 C-61 ❑D-09 ❑Other NUMBER ��k EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE �Domesficf�Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterizadon ata ystem aMe ontact eme or one um er <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other 1 <br /> ❑Monitoring Well(s) #ofwells ❑SoilBoring(s) aofborings 13 Geotechnical xofbonngs 1�J <br /> 13 Well Destruction 13 Out-Of-Service Well ❑out-Of-Service Well Renewal <br /> WELL CONSTRUCTION <br /> 13 Now Pum Pum Replacement 13 Pump Re air 13 Cross-Connection Re air <br /> Drilling Method 13 Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel 0 Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941h bag/5-109.111-111) ❑Sand Cement <br /> sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑pumped ❑1 ree Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width_it Length_ft Thick' in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible ❑Turbine ❑Other <br /> HP J_ <br /> Pump Set),)�-�It Standing Water Level it <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORD:' m\.w <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CEkTIrV THAT MY REQiAS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND TH, I AM IN COMP <br /> WI ete -t L <br /> WORKERS COMPENSA=OALL_&W& ,._ ..__ _ <br /> �L p\ MINIMUM 24 HOUR ADVANCE NO E REQUIRED FOR INSP. ,TIONS <br /> SIGNED�\ c\�� �•�\ TITLE �� `O�• DATE5 � <br /> Xk <br /> 0 1 <br /> \ � 4 <br /> U <br /> ig N E TA <br /> H EAR NT <br /> Aft PARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date 13SPECIAL Well Permit <br /> Pump Inspection Date_ ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received C ee Amount Permit/ <br /> Codes Info B CashRemitted Date Invoice III Well ID# <br /> 164 <br /> 3 � Service Re uest# <br /> d <br /> END 43-02-M <br /> 1/6104 WELL PUMP PERMIT <br />