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SWELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT - 304 E WEBER AVE 34b FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I 0 lyl Z J ( { 8 � '/i+� CITY/ZIP �(, i <br /> CROSS STREET APN O 1 PARCEL SIZE /I t LAND USE APPLICATION# <br /> OWNER NAME J <br /> PHONE �/�/ <br /> OWNER ADDRESS _ I'� 1 1�.w N�9 I CITY/STATE/ZIP Q+'�/+ C.-4 g q-/& r O <br /> CONTRACTOR PC �Y i'VIR/II r�t � iP�t�- 1J 'CTI-a PHONE '714—314 - T ff y <br /> i <br /> CONTRACTOR ADDRESS CI(� 1/V�"�"'�'i 4 AUE CITYISTATE/ZIP !`�"+4•�I+`� <br /> SUBCONTRACTOR PHONE <br /> i <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑C-til D-09 ❑Other NUMBER / <br /> f�45"S75­6 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> i <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> i <br /> ❑Public Water System <br /> Vdifferent From Owner: ater System Name Coniaci Name or Phone um er { <br /> `t i <br /> TYPE OF WORK 61ew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> /❑Monitoring Well(s) #of wells ❑Soil Boring(s) a of borings 13Geotechnical of bor;ngs <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal I <br /> ew Pump ❑Pump Replacement ❑Pump Re air ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary )4Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other i <br /> Proposed Well Depth V5�b ft Excavation17 in diameter ❑Open Bottom Gravel Pack/Gravel Size n diameter, i <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Son. n ❑Steel lastic ❑Stainless Steel I-)Other <br /> Grout Seal Depth /Q7 ft Teat Cement(941h hag/S-10 gal water) ❑Sand Cement suck mix/7 gal water <br /> 13 Bentonite 20%solids) 11 Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method N'umped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor they �f✓'�r1 <br /> Concrete Pedestal Dimensions: Width L/ ft length ft Thick in ❑Christy Box ❑Stove,Pipe <br /> PUMP Submersible ❑Turbine ❑Other HP Pump Set 34:90 ft Standing Water Level .Z,Z�b ft <br /> i <br /> I HEREBY CERTIFY THAT 1 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 E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COM ION LAW --ow <br /> 4 HO ADVANCE NOTICE REQUIR/EEDD FO INSPECTIONS s <br /> SIGNED TITLE '� 'cf�+� DATE A9 7 <br /> I <br /> SEC'.&I SEC.X <br /> /661.11 % 80.3 SEC.2 <br /> i <br /> --SET POINT <br /> ON UNE <br /> z (TYPICAL) <br /> Oil <br /> 'x. O <br /> J A O <br /> (N <br /> O /r O O <br /> M ry <br /> _ m <br /> ANfK j e BULL <br /> ' N O �t�viOe <br /> SN Ojau IN O <br /> APA) 2.63-2.30-r's- j <br /> t�0� <br /> /673.07' r; Lo�A7✓ic7•v— <br /> f it(CEu BOIf��ilh N89'25'53"E rd/f�2' L t <br /> Application Accepted By Date r, Area Employee ID# _ � <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck#/ Amount Date Permit) Invoice# Well 1D# <br /> Codes Info B s Remitted Service Request# <br /> - S OO �59T9avY -7I- <br /> EHD 41-02-006 WELL PUMP PERMIT <br /> A16/04 <br />