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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 <br />CALL (20},1}9.) 995533-7697 FOR INSPECTIONS I YEAR FROM{DAATE ISSUED <br />TEXPIRES <br />�Zx <br />JOB ADDRESS <br />J`I - v <br />CITY/ZIP1hc l <br />_ <br />STREET 1- <br />Z <br />USE # 75 /OL <br />CROSS <br />APN <br />PARCEL SIZE LAND P ICATION <br />OWNER NAME ;D2 e,,:1 <br />PHON <br />2:1 ` <br />OWNERADDRESS L <br />CITY/STATPJZIP <br />CONTRACTOR <br />PHON <br />CONTRACTOR ADDRESS <br />O-', <br />CITY/STATE/ZIP�1 F�"�Yl )- <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATVZIP <br />LICENSE ❑ C-57 ❑ C-61 ❑ D-09 <br />Other <br />NUMBER EXPIRATION DATE V C) <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Pu61ie Water System <br />Ifd�tterent War- atu Syt.. .— Conoxt None or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Wells) # of wells ❑ Soil Boring(s) a of b°nnas ❑ Geotechnical a of boring <br />❑ Out -Of -Service Wgll ❑ Out -0f -Service Well Renewal ❑ Cross -Connection Repair <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 R <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (941b 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 />PEDEWAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width It Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP WSi.ibiricsible ❑Turbine ❑Other HP Pump Set ft Standing Water Level_ _ fl_ _ <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. 1 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 />Grout inspection tly De u <br />Date ores.tnL rr cu r cr uua <br />9 0 <br />Pump Inspection B to ❑ WAIVER Received <br />Constructed Well Depth Z ft <br />COMMENTS <br />PE SC Received ec 1 Amount PermiU <br />Codes Info B —sS Remitted Date Serviceuest # Invoice # Well ID# <br />ERD 43-02-006 WELL PUMP PERMIT <br />1/17/2005 <br />�9y <br />