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=� WELL 1 PUMP PERMIT {�` ) <br /> .,)UIN COUNTY ENVIRONMENTAL HEALTH i ARTMEN <br /> T 304 E WEBE►. 1V 3"FL-STOCKTON CA 95202 (209)468 3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED :4 <br /> I M <br /> CITYIZIP Y <br /> Il s J d <br /> FCROSS <br /> RESS 5 xn <br /> REETS APN �4 <br /> !L7--C�' PARCEL SIZE AND USE APPLICATION# <br /> + PHONE&&* <br /> c. c <br /> OWNERNAME 4n •2c - N,.F.'� <br /> fn� CITYISTATEIZiP <br /> OWNERADDRESS Ind Pw41 y <br /> PHONE �16 <br /> CONTRACTOR & <br /> �y? 7 CITYISTATEIZIPL � <br /> CONTRACTORA DRESS 0 J(! <br /> PHONE <br /> SUBCONTRACTOR �Cuht <br /> CITYISTATEIZ[P <br /> SUBCONTRACTOR ADDRESS <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other <br /> NUMBER C EXPIRATION DATE <br /> 24� <br /> y Township Range Section <br /> GEOGRAPHICAL INFORMATION: Coordinates X <br /> INTENDE US ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> [3 Public Water System ntact <br /> stet ystem Name oante or one um r <br /> If different from Owner: <br /> TYPE OF WORK ❑New Well ClReplacement Well ❑Well AlterationlMAd16cation ❑Other ++ a of borings <br /> N of borings Geotechnical f <br /> ❑Monitoring We1I(s) #ofwe]Is '1 Soil Boring(s) <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New PUMP ❑Pump Re lacement ❑Pump Repair n <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Too] ❑Push Point ❑Other <br /> 'r n <br /> Proposed Well Depth�R Excavation— 71 in diameter [3 Open Bottom ❑Gravel Pack 1 Gravel Size in diameter 'V' <br /> ❑Conductor Casing in diameter I 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(9416 bag/5-10 gal water) ❑Sand Cement sack mix I7 gal water <br /> )(Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Crout Placement Method ❑Pumped V Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width R Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set 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 <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 *4pp 4 Cr r— DATE 0� <br /> L" <br /> 4R I <br /> T <br /> r LI-1 <br /> ;�. O QL INV ,OONfy <br /> P IVII 10MEIVT NL <br /> r, <br /> 3 <br /> DEPARTMENT U E NLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout]nspecti n By*i� Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received , 1 <br /> Constructed Well Depth ft <br /> COM ENTS <br /> PE SC Received heck# Amount at Permit/ Invoice# WellID# <br /> Codes Info ash Remitted Service Request# <br /> k <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/27/2005 <br />