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WELL/PUMP PERMIT <br /> SAN JO' aDUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON4ctFUNDA8LE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED CA <br /> ADDRESS Z L�tf 6R Corr-1 hGt�1[7w 94-T7 _ CITY/ZIP_ 1' l y <br /> CROSS STREET r_1+� APN O/�'v�0~y` PARCEL SIZE _LAND USE APPLICATION# M <br /> OWNER NAME I GQ.K)Y��.. PHONE32 <br /> OWNER <br /> w <br /> OWNER ADDRESS n' ^, 1�`3[I LLI La CtTY/STATE/Z!P —La"-1i:��, � -J e��-- <br /> CONTRACTOR ' pp K f - ._ PHONES„�"/T/TMJ' 1 l� <br /> CONTRACTOR ADDRESS W rAx �. _ CITY/STATE/ZIP�&- 1<-bDn <br /> SUBCONTRACTOR PHONE <br /> N <br /> SUBCONTRACTOR ADDRESS _ CRY/STATEIZIP <br /> LICENSE $C-57 C C-61 C 0-09 U Other _ NUMBER E%PIRATION GATE <br /> GEOGRAPHICAL INFORMATION: CDordih Y Township_ Range Section_ <br /> INTENDED USE j DOmestiGPrivate rrigation/Agricultural 0 Industrial ❑Water Quality Monitoring L Soil Sampling/Characterizaton <br /> 0 Public Water System <br /> If drflerent from Owner. Wale,5ystem Mrne Gortm NaMG or u <br /> rnDer <br /> TYPE OF WORx r;New Well C Replacement Well 0 Well Alteration/Modificabon L Other <br /> Monitoring Well(s) #of wells 0 Soil Boring(s) o of borings C Geotechnical i of borings <br /> Out-0f-Service W II 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump Pump Replacement C Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger C Cable Tool 7 Push Point O Other <br /> Proposed Well Depth ft Excavation in diameter J Open Bottom C Gravel Pack/Gravel Size in diameter <br /> I C Conductor Casing in diameter / Conductor Casing Depth ft <br /> I <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad C Steel F--Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft C Neat Cement(94/b bag15-10 gal water) 0 Sand Cement sack mfxl7 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free F211 0 Other 0 Retardant/Accelerator(name)__ <br /> PEDESTAL Installed By 0 Driller n Pump Contractor 0 Other <br /> U Concrete Pedestal Dimensions:Width ft Length It Thick in 0 Christy Box 0 Stove Pipe (� <br /> &I2 0 Submersible L:Turbine :]Other_ HP Pump Set ft Standing Water Level ft <br /> IHEREBY ER T T I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN 'DUN D ANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND C E ITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COM N TI LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE ED FOR INSPECTIONS <br /> SIGNED - f' •�_ .`— TME ` DATE <br /> � I � <br /> I <br /> I <br /> I <br /> I I I <br /> i I <br /> i <br /> I NVAIENT <br /> t'�..." '-�.::.,r ...>•�.:- - -.ac. Vii::...-c :D AR .A1-E^NrT2TUN=trY +- <br /> I Application Accepted 0 <L Date Area Employee ID# <br /> Grout Inspectlon By^—� Date El SPECIAL Well Permit <br /> Pump Inspection By i��.K .� Date 1d p WAIVER Received <br /> Soil Boring In ection By Data Constructed Well Depth ,ft <br /> COMMENTS_ L <br /> y <br /> PE SC Received Ch Amount Date PermlV Invoice# Well ID# <br /> Codes Into i B Remitted Service R uest# <br /> T12Z 30 703 <br /> EHD 4346 - WELL rPUMP PERMIT <br /> 8NaC8 <br />