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&WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE TMENT 304 E WEBER 103"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> dA <br /> JOB ADDRESS A > <br /> S' CITY/ZIP � <br /> 7 -7 a <br /> CROSS STREET I �^ APN` O J PARCEL SIZE J7` / ZLAND USE APPLICATION# <br /> A) Q C � `Y2- <br /> OWNEROWNER NAME •v PH�ON��E� � � <br /> OWNER ADDRESS L CITY/STATE/ZIP " /`1-42- <br /> CONTRACTOR <br /> �// <br /> CONTRACTOR � � /�' 1 PHONE 1— 2 <br /> CONTRACTOR ADDRESS20�(' l_. `• t K ✓I [ l CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE if /57 [Q/611 ❑D-09 II']�Other NUMBER //` EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTI <br /> Drilling Method Mud R t ❑Air Rotary ❑�u er ❑Cable Tool ❑Push Point Cj Other <br /> Proposed Well Depth M—ft Excavation in diameter ❑Open Bottom `unravel Pack/Gravel Size in diameter <br /> ❑Conduct Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedS2 P 1 ❑Steel ��i6 ❑StainI s Steel ❑Other <br /> CJ.t <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib hag/5-10gal water) 6d Cement sack mix/7 gal water <br /> ❑Bentonite 20 0 olids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method umped ❑FrSp Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL InstalM By ElooDriller ❑Pump Contractor ❑Other <br /> on rete Pedestal Dimensions: Width ft Length ft Thick i ❑Christy Box ❑Stove Pipe <br /> PUMP bmersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft m <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. 1 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 COMPENSATIO WS. <br /> 1 24 OUR ADVANCE NOTIC IRED FOR INSPECTIONS <br /> SIGNEDMTITLE 7DATE/ <br /> 3��h <br /> G 11 <br /> A N T <br /> N <br /> IN <br /> DEPARTMENT USE ONLY I <br /> Application Accepted By ��-- Date h 3 C. Area S 1y Employee ID# <br /> Grout Inspection By t Date O ❑ SPECIAL Well Permit / <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS c'•'cz tti`P(( u_. c-rte K✓ C• S �1 (GE e (���vy CC'/��Cl'vt <br /> PE SC Received Amount Permit/ <br /> Codes Info B Cash emitted Date Service Request# Invoice# Well ID# <br /> q C 9t 22S �'v /� C 0 C-1, <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> R/F/04 <br />