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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 INSPF.("TIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS / Z? 2 US Ile \ CI7Y/ZIP I/1L I� ��tiC / � T <br /> _I 7 <br /> ` _ C <br /> CROSS STREET V�� AIN -Z15C -�7 PARCEL SIZE 2"BP 79 LAND USE APPLICATION# z <br /> Frp�ri Icy ti . r✓ru PHON(� -7) 599- Z9Gp <br /> OWNER NAME Y-, <br /> �1 <br /> OWNER ADDRESS / -7 �LISIII� CITY/STATF/ZIP1 y ,IC2On' �� <br /> CONTRACTOR r �"I T <br /> . 'nPHONF//��J <br /> CONTRACTOR ADDRESS �e_J � 1 CITY/STATFJZIPI(DCSI ` <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS //--�� /CITY/STATEIZ7IP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 Other V NUMBER&G2 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USEDomestic/Private Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> It different from Owner. ettt ysrcm ante Coruct Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Bonng(s) n ofbormp ❑Geotechnical x of borings <br /> ❑Out-Of-ServiceWell ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum Pum Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth 11 n' <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ✓� <br /> ❑Bentonite(200/6 solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length flThick in ❑Christy Box ❑Stave Pipe <br /> V, <br /> PUMP Submersible ❑Turbine 00ther HP Pump Set R Standing Water Level ft \1 <br /> HEREBY CEF6IFY 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 COMPEN ON LAWS. <br /> MINI. M 2 HOUR A 'ANCE NOTICE LIRED FOR INSPECTIONS <br /> SIGNED TITLE / lr DATE <br /> / <br /> N IR 3N=Ilk <br /> / DEPARTMENT USE ONLY <br /> _S <br /> Application Accepted By 4 4Date �0 2 o C'(o Area Employee ID# 4C-r( <br /> Grout Inspection By / Date ❑ SPECIAL Well Permit <br /> Pump Inspection By uS act Date Y ' ❑ WAIVER Received <br /> Constructed Well pth ft <br /> COMMENTS f� c ��, <br /> PE SC "Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By <br /> r�afh Remitted Service Request# <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/278005 <br />