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WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT[I DEPAkiMENT 304 E WEBER AVE 3i°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> V <br /> =t <br /> r' <br /> JOB ADDRESS 1 ! �. CITY/ZIP <br /> r•y �_7 i.�, y <br /> CROSS STREET r rss r r•d ;I r r._ , •�...ri <br /> -. F-�� ! ��- APN I � ��� f•� PARCEL SIZE .. � �� LAND USE APPLICATION# i <br /> y� <br /> OWNER NAME i, 1.^'t I..,',r;:` �r ,n..,-,� i t ,ll(7 PHONE <br /> OWNER ADDRESS I`' :1 (��` •r,- CITY/STATE/ZIP <br /> CONTRACTOR TOR t ' l S.: P'r I'IIONF: <br /> CUN'f11A1'1'f 112 AIJIiR}al CA I'VIS"I A'I'1//.I I' - <br /> ti <br /> SUBCONTRACTOR'\ PHONE <br /> , <br /> SUBCONTRACTOR AtIDRFSS CITYISTATEIZIP <br /> LICENSE 0 C-57 ❑C-61 ❑D-09 ❑Other NUMBER '; %' " ' % ". EaPIRATION DATE � <br /> GEOGRAPIIICAL INFORMATION'. Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Wates Quality Monitoring qSoil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: WaterSysternNarne Contact Name Or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells 171 Soil Boring(s) ^.", !l of borings ff Geotechnical #of borings <br /> a Out-Of-Service Well ❑Out-Of-Service Well Rencwal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pume Re lacement ❑Pump Re air <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary 14 Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth If r! ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter in ThicknesslGaugelASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(44 1h hag/5-I0 gut water) ❑Sand Cement sack mix 17 gal water , <br /> -Bentonite(20%solids) ❑Manufacturer Spec%solids °/ Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped 13'Free Fall 0 Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other i <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft 4 <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE <br /> ~sNOT,ICE`REQU'IRED FOR INSPECTIONS <br /> 14, <br /> SIGNED TITtF D <br /> ATE <br /> 4)tJ <br /> I Pic kvii <br /> i <br /> q I- <br /> � <br /> a.1 <br /> P,0 <br /> t i rl <br /> i <br /> . ,-ty'E_P A'R_'T M''E_N-T.;a.U-���",,•O�N-L y ,. -_. - __ _.. - - <br /> i ` r <br /> Application Accepted DYE `:`/ r,r Date r� r Area Employee IDft / J, ' <br /> Grout Inspection By (`F.Y f ! ,. Date) ❑ SPECIAL Well Permit <br /> Pump InspectionDate D <br /> �• ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> �:OMMENT <br /> `)a I..- T, 4 111 <br /> si <br /> PE SC Received (Check#/,' Amount Permit/ <br /> Codes Info B 'Czrsh Remitted Date Service Request# Invoice# Well ID# <br /> =.T.} ` __f, '' `' f ' :, _r. <br /> rrr J3�33 <br /> ? j .- <br /> - I <br /> �Hp 63-02-006 <br /> I iV7 2005 WELL PUMP HERMIT <br />