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ioal'� <br /> WELL /PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTEI_.._:ARTMENT 304 E WEBEw�.VE 3°o FL-STOCKTON CA 95202 - (209)46&3420NON-REFUNbABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> FJOBDDRESS ���� LIVCITY/ZIP STbt-�Od^j �SZI STREET L-. -t-jL <br /> A ^ (� �Y <br /> PN PARCEL SIZE-1-A_LAND USE APPLICATION#-PAT ©. I V <br /> OWNER NAME G U icoz- 6-TevuV-L 9 <br /> OWNERADDRESS o��j� L%VE C1A" ?NZ PHONE L4')0-(W-;. �? Y? <br /> CrrY/STATE/ZIP 5'rK+N C./4 4j)S'Zk71 <br /> CONTRACTOR W, L-t"S Xr'j Cr PRONE <br /> CONTRACTOR ADDRESS—\ 6 ♦Nv V EY ';�O 1^j-t � 9 <br /> CITY/STATE/ZIP ION ST <br /> SUBCONTRACTOR * <br /> PHONE <br /> SUBCONTRACTOR ADDRESS \1 <br /> CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER F <br /> EXPIRATION DATE d 6 <br /> GEOGRAPHICAL INFORMATION: Coordinates XC <br /> Y. <br /> Township Range Section 0 <br /> DED Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring . ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: aur ystem ame <br /> ontazt ame or one um r <br /> TYPE OF WORK ❑New Well ❑Replacement Wep ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #ofwells ❑Soil Boring(s) aofborings ❑ !� o1 Nofborings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pume ❑Pump Replacement )dx=2 Repair <br /> WELL CONSTRUCMON <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger 0 Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter Cl 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 ❑, <br /> Grout Seal Depth Other <br /> ft ❑Neat Cement(941b bag l5-10 gal wader) ❑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 17 Driller ❑Pump Contractor ❑ Other <br /> Q Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PvMP ❑Submersible ❑Turbine 0 Other HP Pump Set ft Standing Water Leve] ft <br /> I 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. 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 /> MINIMUM 24 HOUR ADVANCE_NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE C>w N�� I P4 E S 1D CN T <br /> DATE L-ZS-c3 <br /> 1 <br /> Iry A 11 <br /> in 17 <br /> T1 I <br /> l <br /> s` <br /> Id <br /> Val O <br /> L <br /> t 6 <br /> DE .RTMENT. . SE._. ; .y <br /> Application Accepted By DateD �[ Area 13Employee ID# <br /> Grout Inspection By ate SPECIAL Well Permit � <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS, <br /> PE SC Received Ch Amount Permit/ i <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well IDN. <br /> k <br /> E14D 43-02-006 <br /> 1/2712005 WELL PUMP PERMIT <br />