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5C <br /> Ifolele4 /3 to 5- 7 WELL 1 PUMP PERMIT ��c <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH UAARTMENT 304 E WEBER3°a FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-RE$biNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOa DDREss Al. M01,dea iW CITY/ZIP • y <br /> CROSS STREET // A P N ID$""f I�2��PARCEL SIZE7' LAND USE APPLICATION# j <br /> OWNERNAME { T�1C11Y7q�, .�. �>t`�2u !✓f?p'fU Pilo <br /> OWNER AIHIHF:SS y�L1 L-�i— _ -- -- C'rry/S'l A'TFJZIP <br /> CONTRACTOR �`J► PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> E <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED <br /> USE ❑Domestic/Private ❑Irrigation/Agricultumi ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water Syszcm Nam,c Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Other <br /> ❑Monitoring Well(s) #of we]Is ❑Soil Boring(s) a of borings ❑Geotechnical 4 of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well RenewalCross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ©Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ElPlastic ❑Stainless Steel ❑Other <br /> Grout Sea] Depth ft ❑Neat Cement(94 1b hag/5-lt7gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File C7 Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fail ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length 0 Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other lip Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND T1;IAT 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 /> yy ,? MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> �V SIGNED 1 R TITLE DATE ��— ?^O s <br /> p;- <br /> F <br /> OC i <br /> SAN JOA Li 1'i <br /> ENVIR <br /> }-iEALT1-II�E A TMEN <br /> L-HE COPPf'RO►OLI!RD <br /> u > A 'l' 117 NT USEO LY <br /> 9 <br /> Application Accepted By Date Area Employee lllr� !/ <br /> Grout lnsRection By Date ❑ SPECIAL Well Permit <br /> R6! lect Date D 7i ❑ WAIVER Received <br /> Constructed l Depth ft <br /> COMMENTS r [ ( iP` - <br /> /.CJ <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# WellID# <br /> Codes Info By Remitted Service Request# <br /> Cl 33 So-9 O ID�7 0 ,e00 5~5 <br /> Elis 43-0Z-006 WELL PUMP PERMIT <br /> 127!2005 <br />