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0 WELL! <br />PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL IllEALTNDEPARTMENT 1868EAST HAZELTON AVENUE -STOCKTON CA96205 - (209)469-3420 <br />NOWREFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Z r ( CAP !q 116 \ V <br />CrrYIZIP <br />, (- (ji; \I L <br />CROSS STREET APIN <br />PARCEL SIZE <br />LAND USE RATION # <br />OVMER NAME a�,` f-, m % S Sn� S� (� <br />4APPLIcI <br />PHONE _ `'J - <br />^� <br />ONMER ADDRESS A� \, <br />S O.�J�A _A -1d <br />CITYISTATEILP <br />(QAC ` C -A <br />CONTRACTOR C G Q C <br />f <br />n <br />PHONE (('\11'\ -\ (Aqk -,t G o <br />CONTRACTOR ADDRESS _t�y\-j �) r �3 Cc PQK Il d <br />CrTY1STATEI7JP <br />l LTC( a (Yi Q f-\\- O l A 9 I <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITYISTATEILP <br />LICENSE 0 C-57 61 ❑ D-09 0 Other <br />NUMBER _tLq-26A\\. <br />EXPIRATION DATE O \ %A <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ <br />INTENDED USE O Domestic/PrNate 0 Irrigation/Agricultural O Industrial O Water Quality Monitoring 0 Soil SamplinglCharecterization <br />O Public Water System <br />ItdiRerem from Oww contact mm or PrMune Nmum r <br />TYPE OF WORK 0 New Well O Replacement Well O Well AfteratioNModftication >Other t \-'(i S O.rc\ Q\ a 9raIn r a <br />0 Monitoring Wells) # of wells 0 Sal Boring(s) a or borings ❑ Geotechnical e m bodngs <br />O Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />0 New Pump_ 0 Pump Replacement O Pump Repair O Raise Weft Casino _. _ <br />Drilling Method O Mud Rotary O AirRotary 0 Auger 0 Cable Tod 0 Push Point * Other QV C- V \ \\ <br />Proposed Well Depth ft Excavation in diameter O Open Bottom 0 Gravel PackkJGravel Sze in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter -1_ in Thidcness/Gauge(ASTM Schad 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft 0 Neat Cement (94 lb bey5-1`0 gel water) 0 Sand Cement sack mix17 gal water <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant /Accelerator (nane) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other <br />0 Concrete Pedestal ODimenslons: Width -ft Length R Thick in O ChrlstyBox 0 Stove Plpe <br />riga 0 Submersible Turbine 0 Other HP _ _ _ Pump Set ft Stand n g Water Level tt <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. 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 />DEPARTMENT USE ONLY <br />Application Accepted By P410 � G Date <br />Grout inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Info By Cash Remitted Date <br />`'�` � � 122 /�• b� `�?/o l3 <br />j38 <br />Area Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth It <br />Irvlce Request # Invoice IT Well IDI <br />Oh (0-1CtW <br />