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VELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE Sao FL-STOCKTON CA 95202 - (209)469-3420 <br /> NON-REFUNDABLE PERMIT C CALL 209 953-7697 FOR INSPECTIONS �E�X,.PI�REES-1 YEAR <br /> FROMDATEISSUED <br /> JOB ADDRESS II��'� 1-6 <br /> ,,�,, '1 rv..r 1 t CITY/Z�IytP1��1 /`t• 7 J 3 y <br /> CROSS STREET-T-Ac- L A)fe-- APN PARCEL SIZE�[,�LAND USE APPLICATION# <br /> OWNER NAME Srr'T Me S Goy 1 <br /> + (]rte-GC.Lis-� PHONE a. o / - 3a <br /> OWNER ADDRESS C_ 7C Z O CITY/STATE/ZIP Lc�14 - 7 nS_Z 3 7 <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> SUBCONTRACTOR PHONE <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 USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ifeiffenmtfrom Owner: Water System Nam Cornet Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) a of bodnp ❑Geotechnical #ofbodngs <br /> XOut-0f-Service Well ❑Out-Of-Service Well Renewal ❑Cross-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 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 wafer) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width It Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT 1 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 /> MI UN} 4 HOUR ADVANCE NOTICE <br /> R�^ p'REQUIRED FOR INSPECTIONS <br /> SIGNED t TITLE�W ra/<.0\ DATE -11,05 <br /> 117 <br /> G <br /> LA LrLL <br /> S \ N Z <br /> 1 j <br /> DEPARTMENT USE NLY <br /> Application Ace Date Area Employee ID# (y <br /> Grout spection By Date ❑ SPECIAL Well Permit <br /> Pump tion Date ����y ❑ WAIVER Received <br /> Constructed Well Depth it �J <br /> COMMENTS / �' <br /> v' <br /> PE SC Received hec Amount Date Pe to J Ice# ell <br /> Codes Info By ash Remitted Service Re uest# •e> <br /> \1 O0 <br /> END 13-02-006 �I-'Y- WELL PUMP PERMIT <br /> l2]R005 <br />