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t <br /> 1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D ' ELLMENT /PUMp PERM 1 <br /> NON-REFUNDABLE PERMIT 30I E WEBER FL-STOCKTON CA 95202 - (209)468-34 <br /> CALL 209 953-7697 FOR INSPECTIONS <br /> FL <br /> SUED JOB ADDRESS � � � <br /> CITY/ZIP <br /> CROSS STREET ��� APN J a <br /> OWNER NAME _ �ARCEL SIZE LAND USE APPLICATION# /?4 0PHONE <br /> Q <br /> OWNER ADDRESS <br /> CITY/STATE/ZIP r <br /> CONTRACTOR A� <br /> • 1 ` <br /> CONTRACTOR ADDRESS PHONE <br /> CITY/STATE/ZIP <br /> SUBCONTRACTOR y � <br /> / <br /> SUBCONTRACTOR ADDRESS PHONE <br /> CITY/STATE/ZIP0012f,Z <br /> LICENSE -57 -61 ❑D-09 ❑Other tDATMEj&j::�NUMBER EXPIRATI <br /> f GBOCRAPHICAL INFORMATION: Coordinates X <br /> Y Township <br /> D 0mCstic/Private ❑Irrigation/Agncultural ❑Industrial p Range Section <br /> ❑Public Water System ❑Water Qualiry Monitoring ❑Soil Sampling/Characterization <br /> Vdifferent from Owner: <br /> ate, ystcm atne <br /> ntact ame or ane um r <br /> OF-WORK ❑New Well or <br /> Well El Well Alteration/Modification <br /> ❑MonitoringWells ❑Other <br /> We]](S)—#ofwells ❑Soil Borings} 40borings <br /> ❑Out-Of-Service Well ❑Geotechnical of borings <br /> ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> e� Pum ❑Pum R p4scement 13 :1 Re air <br /> WELL C_ U^ N T N <br /> Drilling Method Rotary ❑Air Rotary ❑Auger <br /> / -? ���� g 13 Cable Too! ❑Push Point ❑Other <br /> Proposed Well Depth-- - ft Excavation �in diameter ❑Open Bottom <br /> ❑Conductor Casing ravel Pack/Gravel Size . ]Submitted <br /> /� $ in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter !C/ in Thickneas/Gaugc1ASTM Sched - l� <br /> Grout Seal Depth ❑Stee�astic ❑Sul Stec the <br /> ❑Other <br /> p A ft ❑Neat Cement(941b bag/S-10ga1 wale,) and Cement � <br /> ❑Bentonite(20%solids) O Manufacturer Spec%solids ,`e % Name sack m !!-- <br /> Grout Placement Method�- Pumped ❑Free Fall ❑Other // ❑Specs on File ❑Spe �J <br /> d ❑Retardant/Aecelcrator(name) <br /> PED£ TAL Installed By ❑Driller ¢, ump Contractor ❑ ti, <br /> ❑Concrete Pedestal Dimensions:Width <br /> ft Lcngl"-��A. `?•, jThick in ❑Christy Sox ❑Stove Pipe <br /> PUMP �rubmersible ❑Turbine ❑Other d ,- m� <br /> HP Pump Set// ft Standing Water Level , ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THeWjORK 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 /> UM 24 HOUR ADVANCE NOTICE REQUIRED FO INSPECTIONS <br /> SICNED <br /> TITLE S� <br /> k <br /> I' <br /> n <br /> 1110MN <br /> I <br /> 4-T <br /> l <br /> �I <br /> 4 k <br /> li <br /> 1 <br /> DE PA RT MENT�p SE ONLY S <br /> Application Accepted By •^t'�---.� Date <3D 0� A. Employee ID# Q� <br /> Grout Inspection By Date / ��y-ZOVE; ❑ SPECIAL Well Permit <br /> c;eF�Pump Inspection By Date I/— n � 13 WAIVER Received <br /> Constructed Well Depth It <br /> COMMENTS OL--"J L..eTO F R C .1-,j <br /> i <br /> PE SC Received CShecW Amount Permit/ <br /> Codes Info B ash Remitted Date Service Re cast# Invoice# Well ID# <br /> L[31-7 1'q� LCG �6i� 3ZO'� SO1105, 6900,44-141? <br /> Lf3 _ asa 3 gb u�.� o <br /> EHD 43-02006 <br /> 5f2T12005 <br /> WELL PUMP PERMIT <br />