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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. (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE I/S'S'UEED�! <br />JOB ADDRESS <br />CITY121P <br />I' <br />I/D !7-l��� <br />r <br />f <br />'' LL / <br />APN U z 21 f t SIZE LAND USE APPLICATION k <br />CROSS STREET N <br />-'PARCEL <br />`� ✓' <br />PHONE 6J72- ZZ <br />7,6 <br />OWNER NAME <br />OWNER ADDRESS r �K <br />'v � <br />CITY/STATE/ZIP <br />V ' <br />f ! <br />r7 <br />PHONE C <br />CONTRACTORTCONTRACTOR�� C�i <br />C C <br />n 1 <br />1�� <br />CONTRACTOR ADDRESS ' L <br />Ili <br />I YAC <br />Dt <br />p <br />"�S !ted CITY/STATE/ZIP <br />Q jlo <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRA�CtO'�R, ADDRESS <br />CITY/ST''ATFJZIP <br />i LICENSE D&-57 0C-61 <br />0D-09 <br />❑Other NUMBEROe'�lJZL <br />EXPIRATION DATF2�n/ <br />�7 <br />.. IuenvMAT!0-: t'nnrdinates X Y Township Range Section <br />NTENDED USE mestic/Private ❑ Irrigation/Agricultuml 0 Industrial O Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System m r <br />IfdiRerent Gom Owner. aror, ysttm ame ontao ame or ne u <br />TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Tat Hole O Other <br />_ ___ bn/Mrinna <br />❑ Monitoring Well(s)_# of wells ❑ Soil Boring(s) - --- - u treotecnnicat <br />❑ Well Destruction ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair 0 Cross -Connection Repair <br />W f LL CONSTRUCTaoN <br />Drilling Method pi(Mud Rot � Air Rotary ❑ Auger ❑ Cable Tool 0 Push Point O Other <br />Proposed Well Depth a,— n Excavation in diameter ❑ Open Bottom ravel Pack / Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched I6 6�2 ❑ Steel ;4lastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth -7`'''E"— tl 13Neat Cement (941h bag /5-10 gal water) ❑ Sand Cement —k mix / 7 gal watei <br />�entonite (20% solids) ❑ Manufacturer Spec % solids _ % Name ❑ Specs on File ❑ Specs Submitted <br />Grout Placement Method fj&Umped ❑ Free Fall ❑ Other 17 Retardant / Accelerator (name) _ <br />PEDESTAL Installed BY ❑ Driller (;>fltgnp Contactor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width_ 11 Length—ft Thick in ❑ Christy Bax ❑ Stove. Pipe <br />Pump ❑ Submersible 17 Turbine ❑ Other HP Pump Set it Standing Water Level f <br />1 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />NIININ/IUN1 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS /t /' <br />SIGNED 1 G •�tg� "!z,f' TITLE. tr l jI ?Vr DATE A5^ t -!'C2 <br />