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WELL 1 PUMP PERMIT �.� � <br /> ,QUIN COUNTY ENVIRONMENTAL HEALTH-- .'ARTMENT 304 E WEBEk..-*E 31°FL-STOCKTON CA 95202 -'(209)468-3420 <br /> NUN-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED v7 <br /> , ccrt: t�� Cl C-' �! _ <br /> JOB ADDRESSCITY/ZIP a`7 ' tS'F L++a� 5e? �t;� 7 - �— v <br /> �t jc <br /> CROSS STREET S, r •t.0 c'-� li APN I� �!� 'aJ PARCELSIZE *'AAND USE APPLICAT, 4 Ej <br /> EA <br /> OWNER NAMEQ"r4 w-% t/nl.lrt::� tc Sa- •� rSlii PHONE car Z <br /> OWNER ADDRESS ao,c 3;� _ CITY/STATE/ZIP iYt�tt C C'4 T 7 7 <br /> PGki �4.y. <br /> CONTRACTOR PHONE 3c,0 <br /> CONTRACTORA. DRESS ADO V dfro, -I 2 CITYISTATEIZIP AaL Vr <br /> SUBCONTRACTOR 9(m PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 ©C-61 ❑D-09 ❑Other NUMBER 'Y—O15:2 EXPIRATION DATE 7 <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 /> If different from Owner: Water ystem ame Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration) i6cation C]Other <br /> ❑Monitoring Weli(s) #of wells 'P Soil Boring(s) E C <br /> it of borings Geotechnical r 4 of borings <br /> ❑put-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Purnp ❑Pum2 Replacement ❑Pump Repair <br /> WELL CONSTRUCTION ftc1 �V <br /> f0►Y�JtG�L <br /> Drilling Method ❑Mud Rotary [3 Air Rotary Auger ❑Cable Tool 13 Push Point ❑Other <br /> Proposed Well Depth, y0 ft Excavation 7 •1 <br /> in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter I Conductor Casing Depth ft \ <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft 13Neat Cement(94 1h hag/S-!0gal water) 13 Sand Cement sack mix/7 gal water <br /> iBentonite(20%solids) Cl Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped F'Free Fall ❑Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <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 <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 5h,* agj'Ay St- DATE ( -w 03' <br /> n <br /> f� <br /> .Nr <br /> LZ <br /> SAN JOAQLIN O N y <br /> p EIIVIROIWENTI- <br /> In <br /> l <br /> r r- <br /> DEPARTMENT U E N LY <br /> Application Accepted By pate [) fr Area Employee[D# <br /> Grout Inspecti n By Date S- CIWeII Permit <br /> Pump Inspection By Date 13 WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS / <br /> PE SC Received heck# Amount at Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Request# <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/27/2005 <br />