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WELL 1 PUMP PEkMIT LGor- 70�- <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (249)465-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSrJ . <br /> die S CITYIZIP � <br /> CROSS STRE <br /> OWNER NAME ET �QiGG� APN I� y PARCEL SIZE LAND USE APPLICATION# <br /> irn [�� /rL y7 Ce-1r�-q✓� L� PHONE <br /> e U7H /,�/ �J <br /> �D a CITYISTATFJZIP��/ C of S'2-�Y <br /> OWNER ADDRESS /�// Qom,_fin '� /� 7 <br /> CONTRACTOR /V 0 O ��'! .V 14s a- �C PHONE % � ✓ �f' <br /> CONTRACTOR ADDRESS 7 D z _rJA.S�W k/44/ CITY/STATE/ZIP <br /> SUBCONTRACTOR G PHONE <br /> SUBCONTRACTOR ADDRESS wC CITY/STATE/ZIP <br /> LICENSE XC-57 13C-61 ❑D-09 ❑Other NUMBER 6G 7 0I EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural. ❑Industrial ❑ rp)ua nil g t h ra ttan I <br /> ❑Public Water System <br /> If different from Owner: grater SysmName i! -on tMmeofPhoneNumbCT <br /> TYPE OF WORK ❑New Well ' ❑Replacement Well ❑Well Alteration/Modification 1? 1� Lwle expltju <br /> aofnWk being c <br /> I ❑Monitoring Well(s) #of wells ❑Soil Boring(s) W>841 0 r fie; <br /> t ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal Cross-Cvo�nrnoecr�ti l Health D �;�ion <br /> [3 New Pump E3 Pump Replacement ❑Pump REpair p� <br /> WELL CONSTRUCTION <br /> II Drilling Method ❑Mud Rotary ❑Air Rotary 13 Auger ❑Cable Too] ❑Push Point 6p Other PT o <br /> Proposed Well Depth yl-70' ft Excavation Z in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> I ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft PVNeat Cement(94 lb bag 15-10 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 /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ft Thick in ❑Christ Box ❑Stove Pipe <br /> ❑Concrete Pedestal Dimensions:width ft Length Y <br /> iPUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORT{ 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 /> I <br /> IN HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> l SIGNED C ' TITLEJLld-t/I�. DATE 0/1/0 <br /> I'J <br /> I <br /> I <br /> 1. <br /> 9 1!f <br /> 44 ED <br /> 'y <br /> N lR N E <br /> kRl ME N7 <br /> DEPARTMENT U E ONLY H �� <br /> Application Accepted By Date Area Employee ID# 31�e <br /> Grout inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth �i ft <br /> COMMENT C�Jt�E -7toO .c0 LCC° rfn4f � Vrd�rQ [f�/17`LT <br /> I � <br /> t PE SC Received Amount Date PermiU nvoice# WellID# <br /> Codes Info B Cash Remitted Servicc Re uest# <br /> 4-00 <br /> EHID 43-02-006 WELL PUMP PERMIT <br /> 1/2712005 <br /> rx <br />