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WELL/ PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3­FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 I:OR INSPECTIO\S EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CrrY/ZIP �Q ACEI <br /> II l o <br /> CROSS STREET {.I=VpN 1 L \ APN �N' PARCEL SIZE r LAND USE APPLICATION# <br /> OWNER NAME 1 1 ti PHONE <br /> OWNER ADDRESS Al M j 11 Sf, _ CITY/STATIAH? <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE Q <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section— <br /> ND D <br /> ectionNDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System — <br /> Ifdiftbre rfrom Owner: ­ ystem sme unracr erne or < um r <br /> TYPEOF7 New Well Replacement Well O Well Alteration/Modification ❑Other <br /> O Monitoring Well(s #of wells O Soil Bori ng(s) s ofbonnss ❑Geotechnical s ufbonng, <br /> )(Out-0f-Service Wel 13 Out-Of-Service Well Renewal O Cross-Connection Repair <br /> [I New Pump ump Replacement ❑Pump Repair <br /> WE N I N <br /> Drilling Melho Mud ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point O Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom O Gravel Pack/Gravel Sin—in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth tl <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched O Steel ❑Plastic ❑Stainless Steel O Other <br /> Grout Sea] Depth ft ❑Neat Cement(94 1b bag/S-/0 gal water) ❑Sand Cement sack mit/7 gal water <br /> O Bentonite(200/solids) ❑Manufacturer Spec%solids % Name ❑Specs on File O Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> O Concrete Pedestal Dimensions:Width ft Length ft Thick in O Christy Box ❑Stove Pipe <br /> PUMP O Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 /> WOR %COMPENSATION LAWS. <br /> IM 24 HOUR ADVANCE;NOTICE REQUIRED <br /> SFOR INSPECTIONS <br /> SIGNED TITLE )s"�'�/Z� DATE - W <br /> N 0 CII OIL IN <br /> Hi 11E 1JT1L <br /> Ll <br /> ---EFT-1 -N --n <br /> D PARTMENT USE ONLY <br /> Application Accepted By 0- Date Area Employee ID#00 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By _ Date____ ❑ WAIVER Received <br /> Constructed Well Depth ft r <br /> COMMENTS Ala V,}In& <br /> tSt` A� 1 v ID 11`� <br /> PE SC �84� <br /> Check/ Amount Permit/ <br /> Codes Infoash Remitted Date Serviee t# Invoice# WeII 1D# <br /> 3 /00.,- a 10, O <br /> EHD I3A2-0a6 � �'�\wj -,� �1�� L -a, 1��1'WE-LL'PU'M._P4PER�IT <br /> 1278005 'i.► "^���1.1t <br />