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4EL4LTPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 95202 -(209)469-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Cm/ZIP`_!�I✓� y <br /> CROSS STREET/Y, � �J l APN C)(,,-7— ;2-&V-V'7 PARCEL SIZ `J LAND USE APPLICATION# <br /> OWNER NAME ( //��" t1��I �Gz4 PHONE I V - L <br /> OW14ERADDRM /�:i� CTTVISTATE/ZIP <br /> CONTRACTOR / �-1 / z- - <' PHON <br /> , <br /> CONTRACTOR ADDRESS {- CITY/STATElZIP <br /> SUBCONTRACTOR l--)-AJ/'' ,/� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ,.I�'G57 ❑C-61 ❑D-09 ❑Other N .-UMBER //_ EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X V Township Range Section <br /> INTENDED USE .Domestic/Private ❑Irrigation/Agncultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charactcrization <br /> ❑Public Water System or ams _ u <br /> If d Raen1 Crum i)wner: Ws., y— onncl ame m r <br /> TYPE OF WORK i$New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s)_#of wells ❑Soil Boring(s) w urbnnnas ❑Geotechnical a orbodn� <br /> ❑Out-Of-Service Well ❑Out-Of-Smice Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Pump Replacement ❑Pump Repair <br /> W ELL CONSTRUCTION I•,1 <br /> Drilling Method-*fg Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other lJ`1 <br /> n c.9 <br /> Proposed Well Depth ft Excavation/ in diameter ❑Open Bottom Gra Vel Pack/Gravel Siu�_in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter::5_in nickness/Gauge/ASTM Sched ❑Steel )M3'lastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth / = ft ❑Neat Cement(94 It,bag/J-!0 gal wafer) -.�MSand Cement /�- sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method --�RYPumped ❑Fra Fall ❑Other ❑Retardant/Accelerator(name) <br /> PLDFSTAL Installed By riller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width R Length ft Thick in ❑Christy Bos ❑Stove Pipe } <br /> PUMP ,,PT'Submersibic ❑Turbine ❑Other— It P Pump Set ft Standing Water Level R <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 1 AM IN COMPLIANCE WITH ALL T <br /> WORKERS COMPENSATION LAWS. ,U <br /> INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS Lj <br /> SIGNED ,/�--- TITLE DATE <br /> 11.l- b <br /> 11v c <br /> 2yb <br /> ml- <br /> 30.r <br /> I LJI 4 1 V 1 1 1 P"'I <br /> u, G <br /> -74 V114 <br /> N lR <br /> N <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date -7 /-5 U r Area Employee IDN <br /> L <br /> Grout Inspection By T Date 2 0-r ❑ SPECIAL Well Permit <br /> Pump Inspection By Date S-�' ❑ WAIVER Received <br /> Constructed Well Depth SS 0&5 R <br /> COMMENTS!sC* -6A,) 3SS'a7S - 24'' <br /> PE SC Received Chet Amount Date Perm1U Invoice# Well ID# <br /> Codes Info B Cash emitted Service Re ucat# <br /> f 3 & 1 o Z2S oo 0 wP a <br /> ;av osa so oa -py q3v5 <br /> WELL PUMP PERMIT <br /> EHD 4342-006 <br /> 1127/7005 <br />