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^}1rt 15 <br /> • (7WELL 1 PUMP PERMIT <br /> SAN JOAQUI COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER A-YE 34"FL-STOCKTON CA 95202 - (209)468-3420 <br /> N - EFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> MC�i-1 5 3 t-+riM - `/`r � LA" l:_ CITY/ZIP � 1 V�.4C�� r" � <br /> JOB ADDRESS a <br /> 17-0..._.030--Ci I M C <br /> CROSS STREET vsl EST .._APN f 2-C, -o-;W`c>y- PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME �� 1�-y -� 1 �J CSV '2-,Cl ^[:)Zu--CY7 - -- PHONE � <br /> �� <br /> I <br /> OWNER ADDRESSgr,.�� CITY/STATE/ZIP <br /> tw <br /> CONTRACTOR ✓ .j /^ ,may J[Zr1�CM�J`� -r-` PHONE <br /> Q4N Oil- <br /> CONTRACTOR ADDRESS ,A�Cy t"7C]�'/ JVIp�1�/"---/ Y/^ CITY/STATE/ZIP r� ��j I <br /> SUBCONTRACTOR VLA IV PHONQE l <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE YS,57 ❑C-61 ❑D-04 ❑Other NUMBER o I EXPIRATION DATE <br /> 1 <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: Waier System Name Contact Name or Phone Number <br /> I <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) #of wells Il Boring(s) ofborings Veotechnical #orhorinbs <br /> ❑Well Destruction 0 Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Re air <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> ri <br /> Proposed Well Depth (5--..3 U ft . Excavation6 in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ftcf[' •..a <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ElSteel ❑Plastic 11Stainless Steel Oiher !�GcL <br /> .v t'T r.� <br /> Grout Sea] Depth ft ❑Neat Cement(94 I6 hug 15-10 gal water) ❑Sand Cement sack tnr <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Ua <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) �Y <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove,Pipe <br /> rt, <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I 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. 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 <br /> �REQUIRED <br /> �FOR INSPECTIONS g � <br /> r1 +�1d-J - C�l't l$��t <br /> SIGNED_ TITLE DATE <br /> r - <br /> 4 <br /> t <br /> COUNT,( ,� � �� E k <br /> N 1Ft N E _ <br />:+ : ,��-HEALrHp y <br /> .,r �.. DEPARTMENT USE ONLY <br /> Application Accepted By Date 3IL) Area . 1 Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump <br /> inspection By Date ❑ WAIVER Received <br /> JlegaLgton Inspection B Date Constructed Well Depth ft <br /> .COMMENTS A/6 731 /*�6 ZAP <br /> .�/�lar�'J �dL /�OlTlo�.�✓�-G�:.��,;.�-4�"�. l�l�Cr�11C � �2 -r/ <br /> PE SC Received hec Amount ate Permit/ Invoice# Well IDN <br /> Codes InfoB ash emitted Service Request# <br /> ' 3 7 r 5ci tw��V"t) ... ),?F1 <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 316!04 <br />