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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DWARTMENT 304 E WEBERt e 3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS cm L7n✓'t./ /57J'�� ta4 <br /> CROSS STREET_ CQ I r APN PARCEL SIZE , G LAND USE APPLICATION# <br /> OWNERNAME ---K-7� \1r • %xncmYl _ PHONE Skb) `4412 8763 <br /> / y <br /> OWNERADDRESS ' �f \ t;o ]Ux Care CITY//STATFJZIPr'C-C;b C `- 9�i37A <br /> CONTRACTOR U)cA m 4� �4� N e G {A_!:: ��i+4\!k PHONE (�'/ }3`�i�B l f-I <br /> CONTRACTOR ADDRESS 0;zc� Y,S9 CITY/STATE/ZIP \ g�A CC,."TTT� �� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS ,.// CITY/STATE/ZIP <br /> LICENSE E3 C-57 0C-61 13 D-09 Gb&her � CIO NUMBER 'Y_391_3_2EXPIRATIONDATE <br /> GEOGRAPHICALINFORM ON: Coordinates X Y Township Range Section_ <br /> r <br /> ENDED UBE mestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charmteriration <br /> ❑Public Water System <br /> Ifdilfermtfmm Own.: Wwe,S,W.N.. C..Mt ameor Ph.e Nu.b. <br /> 7 <br /> TYPE OF WORK ew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Wells) #of wells ❑Soil Boring(s) x of bonne ❑Geotechnical s of bonngr <br /> ❑9POf-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ffNew Pum C3 Pump Replacement ❑Pump Repair / r� <br /> WELL CONSTRUCTION ` 'y <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other `(n' <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sim in diameter lJ J <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter _in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other O <br /> Grout Seal Depth ft ❑Neat Cement(94 1b bag I5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on Filc ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Coner to Pedestal Dimensions:Width ft Length R Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible ❑Turbine ❑Other HP Pump Set 1Ga R Standing Water Level ft <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. 1 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 /> MINIMUM <br /> \ 24 HOUR ADVANCE NOTICE REQUIRED FOR <br /> 1 INSPECTIONS <br /> SIGNED OV\\C\ QW C:\ `\df'] TITLE" M� C�'h DATE <br /> d Kf <br /> 0 <br /> FT F <br /> 0 <br /> S <br /> - u <br /> E .R vi N <br /> r a <br /> E AIR MENT U ' E ON --Y <br /> �4E <br /> Application Accepted By4 Date Area Employee IDV <br /> Grout Inspection Date Cl SPECIAL Well Permit �7 <br /> Pump Inspection By 1t /![S/ofLb Dau b t� ❑ WAIVER Received <br /> Constructed Well Depth <br /> COMMENTS d �" <br /> PE SC Received eek#/ Amount Date Permil/ Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> qgzUS !s�5 l� S oS 2©0 IF 9 ?-'9 <br /> EHD 43-02-M WELL PUMP PERMIT <br /> IQ7/2005 <br />