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i - WELL l PUMP PERMIT " <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 301 E WEBER AVE 3-FL-STOCKTON CA 95202 -(209)46-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATP ISSUED <br /> 1.2 v✓' S fl <br /> JOB ADDRESS CITY/ZIP 9 <br /> /J r 3lti2a <br /> s CROSS STREET R' SU�/�;✓ y�CAP7J�]' PARCE 1 .USE PPLICATION# $ <br /> OWNER NAME if �(iC/ //may/( (,� PHONE / / f�� >U•; <br /> �OWNERADDRESS AXAA CIT'/STATE/ZIPQ?'�L�L/ <br /> kno ea <br /> CONTRACTOR C / sI T�PHONNE//�j�&�/-7/'9-?-,{jr <br /> CONTRACTOR ADDRESS O 5- 16 lY CITY/STATE/ZIP / A ( [(eXt (if�T /6' <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATF/ZIP <br /> LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER 4163 2/ EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domes'c/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> lic Water Syystem <br /> If diRttent fmmbwnor: Water System Nam Contact Nameor Plume Number <br /> TYPE OF WORKew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> C3Monitoring Well(s) #of wells ❑Soil Boring(s) x of borings ❑Gcotec cal YF x of Iyd <br /> ❑Out-Of-Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method R ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth_W _ft Excavation // in diameter ❑Open'Bottom ❑Gravel Pack/Gravel Size � in diameter <br /> ❑Conductor mg in diameter / Conductor Cuing Depth ft <br /> Well Casing Diameter T� Thickness/Gauge/ASTM Schcd ❑Steel � ❑Stainless Steel ❑Other <br /> Grout Seal Depth Tt� ft ❑Neat Cement(94 Ib bag/S-10 gal water) and Cement l� 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) r <br /> rAL Installed By ❑Driller ump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length fl Thick in ❑Christy Bos ❑Stove Pipe <br /> Pump ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft ry] <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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> ��rLL MIN UM 24 HOUR ADVANCE NOTICE{{J�'/gUIRED FOR INSPECTIONS <br /> SIGNEw/t TITLE�/ DATE —� —O <br /> I <br /> 4 21,n <br /> N N <br /> lit Fi DEI <br /> IVG <br /> DEPARTMENT USE O N L Y <br /> Application Accepted Date d Area Employee ID# <br /> Grout Inspection By i Date 1 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Constructed Well Depth It A <br /> COMMENT'S k)z S fi dS rT e- � 5 $ <br /> G1 �o Q <br /> PE SC Received Cheek# Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request k invoice M Well 1D# <br /> Z <br /> 5 <br />