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1+(x05—55{o <br /> WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3A°FL-STOCKTON CA 95202 . (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 � <br /> JOB ADDRESS 3�i 3 Z 3 3 1..'f t��l O l,�l.`C 'k ytAl. CITYIZIP <br /> [� b <br /> CROSS STREET � � [�Q APN p '1 E` + PARCEL SIZE 'Z`/ LAND USE APPLICATION# <br /> OWNER NAME �� Sc oP�� ���U` DA- S-4- —I-D4,e PHONE K <br /> OWNERADDRESS 3 332 V`1>1t'10tR_fVA Vr> CITYISTATEIZIP SToC�cTot� CSP[ a520z <br /> CONTRACTOR AIF-11, 0. 40Ds9s.00 , "SDuATE5 PHONE 3 b'I -"3701 <br /> CONTRACTOR ADDRESS CITYISTATEIZIP L Db% Cl'k !q!5'_2_+0 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE XC-57 ❑C-61. ❑D-09 ❑Other NUMBER 04: <br /> TI•N D TE C <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Ra ct <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quati�i2gq j*luay h bi�R1� ftlo <br /> 13 Public Water System it'' <br /> It different from Owner: Water System Name worka <br /> isputed <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑O 1_Tyimr '-.,ial Health —vision <br /> CJ Monitoring Well(s) #of wells ,Soil Boring(s) 14_4 a of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION CI`ti <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other <br /> GI <br /> Proposed Well Depth 10—15- ft Excavation6 in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter N <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other W <br /> Grout Seal Depth ft ❑Neat Cement(94 lb hag/5-10 gal water) ❑Sand Cement sack mix/7 gal waterJELIl °o <br /> +- 7T Gc , <br /> entanite(20%solids) ❑ BACk FILL sv► <br /> Manufacturer Spec%solids % Name 1 F A V Ar., , COO on File ❑Specs Submitted � <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ther <br /> ❑Concrete Pedestal Dimensions:Width Length ft Thick in ❑Christy Box ❑Stove Pipe (� <br /> ^� <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pum t ft Standing Water Level ft <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 /> INI+MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED / TITLE � �� � DATE <br /> 1. I 1 ICI- Ll <br /> RECEIVED <br /> +aar4 <br /> "FRa s Bk_ 3 2005 <br /> R IIB 770 OCT 1 <br /> 4° 114 113 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL r z 7Op" <br /> IZIYEA, }iEALT E <br /> n <br /> 4 ` ° H E 12 ✓ <br /> 2 (2 - o - <br /> 1 43 <br /> 9.4TAC. ;uIYC - <br /> q W I — S!_ <br /> �! <br /> H _ sr urn awm v�aa m nrr e A k <br /> � 29 <br /> DRI e Q 32 <br /> i <br />_ �LL <br /> DEPARTMENT USONLY <br /> Application Accepted By _ Date r Area Employee[D# A <br /> Grout Inspection By Date 13 SPECIAL Well Permit <br /> Pump Inspection By Date © WAIVER Received <br /> Constructed Well Dep h It <br /> COMMENTS / fi/ <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# WellID# <br /> Codes Info B ash Remitted Service Request 9 3�'-� <br /> I <br /> r <br /> t <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 112712005 <br /> _�--- 'mow. .�_ - - �. '•�.. � <br />