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WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE Va FL-STOCKTON CA 95202 - (209)465-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> l7� .V _ CITYIZIS 7'�riJl��l� l o'`�� r� <br /> JOB ADDRESS P > <br /> A ie- <br /> CROSS STREET APN 1 -7 PARCEL SIZE LAND USE APPLICATION# <br />` OWNERNAME �[�`�.7PA- IL� o/4i�i('i.,o I ars+ , _�. PHONE. <br /> OWNER ADDRESS CITYISTATE/ZIP <br /> CONTRACTOR- ALGA_$ I ".a PHONEY y�� <br /> CONTRACTOR ADDRESS ��Z &t p-,��/L-�A'I CITYISTATEIZIP �&/. /.....C?� <br /> SUBCONTRACTOR PHONE <br /> I SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE C-57 ❑C-61 r ❑D-09 ❑Other NUMBER EXPIRATION DATE d <br /> l G£OGRAPHICALINFORMATION: Coordinates X Y " Township Range Section <br /> l INTENDED USE - ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial:; ❑Water Quality Monitoring Poil Sampling/Characterization <br /> ❑Public Water S stem <br /> If different from Owner: WaterSystemNarne Contacf Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/ModificatiJ, i':A t " ❑ r <br /> ❑Monitoring Well(s) #ofwells Soil Boring(s) of'b0 " ❑ echmesl nnSs <br /> ❑Well Destruction El Out-Of-Service Well 1 ` C} ,S�rr u l R �ted without r <br /> E3 New Pum ❑Pum Replacement ❑Pum Repair t�� rossi `onnriection R <br /> 11+ a r pectet <br /> WELL CONSTRUCTION or . 11 j� � <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Ar ❑Cable Tool ❑Push i int ❑, + „f+h C1it jinn <br /> Proposed Well Depth R Excavation in diameter ❑Op t7 Bottom f Grave ack 1 Grave!Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameterin Thickness/Gauge/ASTM Sched 11Steel ElPlastic ❑Stainless Steel 13Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib hag 15-10 gal water)' - ❑Sand Cement sack mix 17 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 ct El Other <br /> ❑Concrete Pedestal Dimensions: Width ft Le gth Aft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other H ump Set ft Standing Water Level ft <br /> WELL DESTRUCTION 0 Open Bottom ❑Gravel Pack_.. ❑Unca ed ❑Other <br /> e Mr, <br /> eptT <br /> Depth ❑ e P ora <br /> e Material ❑N C15 g ❑Sa Cement c'k m 7 gat er entonit ell <br /> ❑ 20% an ctsolids _ ame e ' bm <br /> 1 <br /> {' Place nt Method ❑ eee llOther <br /> mplete w w grade ❑ to to Existin ur Pad <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 /> I MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE pn= q DATE e. <br /> Fam;iy _ ❑ u� <br /> Homes � <br /> u � <br /> N - A ;iingle - <br /> 5th 5t�q � Fami4y � NightingalcAvenve <br /> 0 Homer, <br /> 5ingle Vacam, m Single " <br /> i Family South Forrior ,Ingfe �; Family <br /> Horner, Yamii He„c m Homes <br /> .� <br /> aarr ,Jp <br /> Hnme. I <br /> 5ing,e Family Home. r <br /> 5ir:au: S'mgle <br /> r G. Fa ni3 L <br /> 1 <br /> Fa <br /> ,a°!2 mily <br /> - 1.. -omra <br /> HomeS � <br /> E) <br /> L Application Accepted By . Da tc 'Area�� Employee ID# <br /> r. _Grout Inspection By 'I '- Date- ❑ SPECIAL Well Permit t/! <br /> Pump Inspection By Date ❑ WAIVER Received' <br /> Destruction Inspection By k Date a Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received heck# Amount: Date -' Permit/ Invoice# Well ID# <br /> Codes Info 8 ash Remitted Service Request# <br /> C90 a) S <br /> EHD43-02-006 MASTER WATER WFLL PERMIT <br /> 12122!2403 <br /> , <br />