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-WELL/PUMP PERMIT <br /> SAN JOAC/JND)A <br /> Y NVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REPERMIT CALL 209 953-7697 FOR INSPECTIONS /EXy/PARES 1 YEAR FROM DATE ISSUED <br /> / "��� N <br /> Joe AD�.Es/ZVOCIrr21P 9~CROSS APtia ' PARCEL SIZE LAND USE APP(CATION# m <br /> �f N <br /> OWNER NAME C� HONE N <br /> OWNER ADDRESS9E CITYISTATE/ZIP <br /> CONTRACTOR avic- FanP NE <br /> CONTRACTOR ADDRES t CITY/STATEIZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS C /ST T JZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 0 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE 0 Domestic/Private rrigation/Agricultural 0 Industrial 0 Water Quality Monitoring D Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner. Water ys em ame Contact Name or Phone Numt,er <br /> TYPE OF WORK ew Well 0 Replacement Well 0 Well Alteration/Modification ❑Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) #of boring. 0 Geotechnical #of borings <br /> ❑Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump ❑Pump Replacement 0 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ud Rotary 0 Air Rotary ❑Auger 0 Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth—SOft Excavation IK in diameter D Open Bottomravel Pack/Gravel Size_ in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter L?in Thickness/Gauge/ASTM Schad 0 Steel lastic ❑Stainless Steel 0 Other <br /> Grout Seal Depth JZ ft ❑Neat Cement(94 It,bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> 0,9'entonite(20%solids) 0 Other <br /> Grout Placement Method Umped D Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other <br /> 0 Concrete Pedestal Dimensions:Width It Langlh ft Thick in 0 Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible0 Turbine 0 Other HP Pump Set ft Standing Water Level It <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 COMPENSATION LAWS. <br /> M 24 HOUR ADVANCE NOTICE R IRE NSPECTIONS <br /> SIGNED W47 Aeo <br /> TITLE DATE <br /> I <br /> NI <br /> '-111 IFC;Ll <br /> INRE <br /> C U <br /> PIA <br /> DEPARTMENT USE ONLY <br /> Application Accepted By ILL _ Date t I D Area D y z Employee ID#_�JT°uv(G <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth H <br /> COMMENTS <br /> PE Sc Receivedheck# Amount Dat Permit/ Invoice# Well ID# <br /> Codes Info agoRemittedService Request# <br /> 60 5fC bsw <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8/04/08 <br />