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WELL 1 PUMP PERMIT <br /> SAN JOAQUiN COUNTY ENVIRONMEWAL HRALTH DEPARTMENT 304 E WEBER AVE 3'"FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL, 209 953-7697 1'011 INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> A w <br /> JOB ADDRESS mf����CA qs 7S-3 <br /> CITYIZrP_ !! a <br /> e <br /> CROS9STRELTLQr_-- ee_ APN — PARCEL SIZE 4J.1"7LANDUSRAPPLICATION# T <br /> OWNER NAME SJ— S PNON� gJ 8Z3-(099 r <br /> i OWNER ADDRESS 1S1C� S f �j�C` � rj CrrYISTATLrLIP <br /> CONIRACIOR /UNIS <br /> PHON ZO <br /> t <br /> CorrrRAcroot ADDRESS _2_15 V j o_i n � 9s:%,6 <br /> 1— <br /> SUBCONTRACTOR PRONE <br /> SUBCONIRACIOR ADDRESS Crff/STATFJZTP_ <br />! LICENSE ❑C-57 ❑C-61 ❑D-09 Other_C�� O NUMBER�7�n Z"7-3 EXPIRATTUN DATE d b <br /> GEOGRAPHICAL INFORMATION: Caardiaates X Y Township Rango Section_ <br /> INTENDED UsE Domestic/Privato ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring O Soil Sampling/Charaeterizstion <br /> 13 Publse Water System <br /> if aiRaent Tram Oaser: ata yrorm qac wtams or a em r <br /> TYPE Or WORK 0 New Well ❑Replacement Well ❑Well Altenstion/Modification ❑Other <br /> ❑Monitorings s surbaly urisorbo"nor <br /> Well(s)_____#p ofwells t7 Sail Boring(s)g() ❑Geotechnical <br /> ❑Out-Of-Service We 1 13 Out-Of--Service Well Renewal ❑Cans-Connection Repair <br /> ❑New Pum Pum R lactuncnt 13 Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary 13 Air Rotary ❑Auger ❑Cable Tout ❑Push Point ❑Other <br /> Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> C3 Conductor Caning in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/GaugdASTM Sched O Steel ❑Plastic O Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(1941h bagl5-10 gal water) ❑Sand Cement_ sack mix 17 gal water <br /> O Bentonite(209/o solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method 13 Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> AL Instilled By ❑Driller ❑Fump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width R Lengtb fi Thick in ❑Christy Box 0 Stove Pipe <br /> PUMP Submersible ❑Turbine ❑Other HP Pump Set I - it Standing Water Level 1t <br /> 1 HEREBY CERTIFY THAT l 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 MV 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 /> MI I M 2 IIOUit VANCE NOTICE QUIRED F?R� INSPECTIONS <br /> SIGNED Tl DATE <br /> i <br /> I <br /> 14 <br /> I Ilk , N 1 -1-11 1 'r ,-IV I <br /> r � <br /> - - D Ayj <br /> R -DENT USE NL <br /> Application Ateepted B Dale Area Employe ID# <br /> Grout Inspection By - Date 17 SPECIAL Well Permit <br /> Pump inspection By�A .or,�i _ Date _7/.3/426 ❑ WAIVER Received <br /> Constructed Well Depth It <br /> COMMENTS - , <br /> PE SC Received :Chec Amount Dote Permit/ <br /> Cod Info B emitted Serviceltenuestfi Invoice# Well IDN <br /> EHD41.02406 . <br /> i M7/2005 WELL PUMP PERM]T <br />