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rsyELL/ PUMP PERMIT (-9144 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPe.-i'MENT 304 E WEBER Avc, JaP FL-STOCKTON CA 95202 - (209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL. 209 953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> JOB ADDRESS T Z CITY/ZIP -�C �I�i V�Z� <br /> CROSS STREETF=P�Yv ui APN 10 1- SO— -PARCEL Z V <br /> ` ` ,LAND USE APPLICATION <br /> OWNER NAME � ' �1 � U <br /> PHONE <br /> 9g3� ri3�Q� <br /> OWNERADDRESS � k—^1::100A0 - CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE 0 C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section ! <br /> INTENDED USE ❑Domestic/Private E3 Inigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> if different from Owner: Water System Name Contact Natne 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 bO°' ❑Geotechnical N of borings <br /> [3 Out-Of-Service Well ❑Out-Of--Service Well Renewal Cross-Connection Repair <br /> ❑New Pum ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION �r <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Toot ❑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/GaugeJASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other m <br /> Grout Seal Depth ft ❑Neat Cement(941b bag/5-10 gal 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 ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other Q <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible 13 Turbine C3 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 C PENSATION LAWS. <br /> NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIC TITLE �`� ()W f4 f—. J DATE <br /> Ek <br /> 5 <br /> All- <br /> i <br /> r <br /> RC C :)Ui <br /> P L s <br /> j< <br /> I <br /> .. <br /> DEPARTMENT USE ONLY v �/ <br /> Application Accepted By Date t I � Area Employee ID# /C3�� <br /> rout Insp tion By Date [3 SPECIAL Well Permit ((( ///` <br /> pPtnap Inspection By_ Date� /J` ❑ WAIVER Received <br /> 4i <br /> Constructed Well Depth ft <br /> COMMENTS S C­:g ra Q5— L-A GQ^/0 1 77 6 rJ A— . /� r�J �' A7 <br /> PE SC Received Qe-cw Amount Permit/ <br /> Codes Info B Cash emitted Date Service Request# Invoke# Well ID# <br /> `3.77 OS O (r '!—� D.tAD 2 rL OS 5 L/:5 `7 <br /> EHD 43-024)D6 WELL PUMP PERMIT <br /> 1R7r24D5 <br />