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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3®FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED y <br /> JOB ADDRESS J J L� /¢• ��� C17Y/ZIP e4--� <br /> 0 <br /> �CROSSSTREET , �1,�Fr K APN O�LV/+ .t /IJ SPARCEL SIZE a �LA!iD USE APPLICATION it <br /> OWNERNAME f -y '� 7C.1SATE111IP <br /> PHONE�� 2� `LI <br /> L.CL , <br /> OWNERADDRESS <br /> CONTRACTOR7� ��aG[ OrGyJ,',•G ,fin PH/ONE � <br /> nL/��l T�t� <br /> CONTRACTOR ADDRESS V Y �• _I �/C///�Y�LI/�• CITY/STATE/ZiP ` el I <br /> PHONE <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS CITY/STATEiZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Ranee Section_ <br /> INTENDED� ❑Domestic/Private ❑IrrigationtAgricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public W ater S tem rc: u,e o N <br /> fa;tr�tfrom . r ys= ame <br /> TvPE OP WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other w ofbonn� <br /> ❑Monitoring WOR(s) #of wells 13 Soil Boring(s) µof borings O Geotechnical <br /> �(Oui-0f-Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair <br /> l❑`New Pump ❑Pum Replacement ❑Pump Repair <br /> WELL CONet'RUCffON 1 <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth It 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 ThicknesVGauge/ASTM Sched 13 Steel ❑Plastic ❑Stainless Steel D Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement 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) <br /> ti <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> El Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Boz ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENS Ws• J <br /> U 2 OUR ADVANCE NOTICE/RE`QUIf7T��p FOR.JN,%PECTIONS <br /> SIGNED /L. ✓ TrTLE ( /JVt/!A y DATE C7 J <br /> tt�GG <br /> : <br /> , <br /> +_{.—L..i...�.... � jr I <br /> ...j. �... I _�.. .}-L...� Y <br /> I <br /> j4 <br /> t <br /> r ; <br /> ., E ARTMENT US ON Y <br /> Application Accepted By .�L Date c3 Area f- Z Employee[D# J <br /> Grout Inspection By Dau ❑ SPECIAL Well Permit /t/q <br /> Pump Inspection By Dau ❑ WAIVER Received <br /> Constructed Well Depth R <br /> COMMENT (S -?mac^' <br /> PE SC Reeetved Choc Amount Permit/ invoke# Well IINi <br /> Codes Into B ash Remitted Date ServIce R uest# <br /> -7 <br /> wP11.PUMP PPR\UT <br /> ERD 4143-006 <br /> vn11006 <br />