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';WELL 1 PUMP PERMIT ` ' i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Dkx RTMENT 304 E WEBER,. 3Ne FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7097 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z � I JSr �G� CITY/ZEP/r/��yr q 5 3 5 G <br /> •� <br /> b <br /> CROSS STREET _ APN 2—A--- PARCEL S,zF 2' LAND USE APPLICATION# <br /> OWNER NAME { PHON Z '?' 7 <br /> OWNER ADDRESSI Z 7_ \ I CITY/STATE/ZIP �� ALT co <br /> CONTRACTOR PHONE _ <br /> CONTRACTORADDRESS 2 is- <br /> ( h� CITY/STATEIZIP� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 Other C) NUMBER Z7.3 7, EX IRA 10 E <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INT7ENDED USE ❑Domestic/Private ❑Irrigation/Aocultural ❑Industrial 13 Water Quality Monitoring ❑Soil Sampling/Characterization <br /> Public Water System <br /> if different from Owner. ater ystem ante Contact acne or one Num r <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Borin s a afborings ❑Geotechnical #of borings <br /> gO <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump XPumpRe lacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other3 <br /> Proposed Well Depth ft Excavation in diameter 13Open Bottom ❑Gravel Pack/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 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water i <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted j„ I <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other <br /> [3 Retardant/Accelerator(name) ", J <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP JtSubmersible ❑Turbine ❑Other HP___2_Pump Set 00 ft Standing Water Leve! I.� ft <br /> I HEREBY CEIkTIFY 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. 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 i <br /> WORKERS=N ION LAWS. <br /> MINI Z4 OUR, VANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED moi' TITLE DATE <br /> r <br /> Oil" I I LAI <br /> JU <br /> I <br /> 7 <br /> v <br /> q <br /> 1 � <br /> d A LIl L <br /> h TA <br /> - DEPARTMENT S E O N L Y <br /> Application Accepted By k Date Area Employee ID# ���S <br /> Grout Inspection By Date V © SPECIAL Well Permit <br /> i� <br /> Pump Inspection By Date 0 WAIVER Received <br /> Constructed Well.I) pth ft <br /> COMMENTS <br /> PE SC Received Check#! Amount Permit! <br /> Codes Info B s emitted Date Service Request# Invoice# Well ID# <br /> i <br /> i <br /> END 43-02-006 WELL PUMP PERMIT <br /> 1!27!2005 <br />