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* WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE,-.tTMENT 304 E WEBER Aa6 FL-STOCKTON C5209)468�3410 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM VXTj1' <br /> 2. S 71_7 <br /> JOB ADDRESS CTTYIZI P M <br /> a <br /> CROSS STREET •� f . APN PARCEL SIZE 12•WrLAND USE APPLICATION# <br /> u2 <br /> OWNER NAME PROM��) <br /> OWNER ADDRESS CITYISTATEIZIP <br /> CONTRACTOR E' �C <br /> PHON <br /> CONTRACTOR ADDRESS ' ( n CITYISTATEIZIP n <br /> SUBCONTRACTOR PHO <br /> LIN mril <br /> SUBCONTRACTOR ADDRESS �y CITYISTATE/ZI+P� <br /> CENSE ❑C-57 13C-6l ❑D-09 Other - lJ NUMBER CEXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township! Range Section <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring O Soil Samplmn Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone um r <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Weil Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Borin s #of borings #of borings <br /> gO ❑Geotechnical <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump XPumpReplacement ❑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 I Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lh hag/5-14 gal water) ❑Sand Cement sack mix 17 gat water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible ❑Turbine ❑Other HP Z_ Pump Set bo ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN I <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 COMPS ION LAWS. <br /> MINIM 24H UR ADV NCE NOTICE EQUIRED FOR INSPECTIONS <br /> SIGNED TITLr ` /'- DATE w f <br /> I <br /> �V lhcN T <br /> r- - <br /> "D <br /> _Ti <br /> u i <br /> D PAITh IEI� <br /> iP- DK P R T M ENT U5-E NLY _ - <br /> Application Accepted By _ Date Area Employee ID#., <br /> Grout Inspection By Date ❑ SPECIAL,Well Permit <br /> Pump Inspection By Date 3 D(, ❑ WAIVER Received j <br /> Constructed Well pth ft ell <br /> COMMENTS <br /> d <br /> PE SC Received Ch Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> D 106 ob y q--f,r 3 <br /> I <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1!27!2005 <br />