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WELL I PUMP PERMIT <br /> SCANNED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L._..ARTMENT 304 E WEBER 3 R FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> q <br /> JG <br /> 'JOB CITYIZIP <br /> 2 <br /> tv <br /> CROSS STREET AP�N"- �sr �-2-✓PARCEL SIZ �LAND USE APPLICATION# <br /> OWNER NAME I n PHON ? <br /> OWNER ADDRESS �w CITYISTATFJZIP <br /> 9 <br /> PHONE <br /> CONTRACTOR (/may <br /> iCITYISTATEIZI * <br /> l CONTRACTOR ADDRESS <br /> 1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP 1, <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 Other NUMBER dzj,�G+ EXPIRATION DATEPL�% " W <br /> I <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> Domestic/Private C3 IrrigatiWAgricultuml ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner! Water System Name Contact Name or one um r <br /> a PE F WO ❑New Well 0 Replacement Well ❑Well Alteration/Modification ❑Other } <br /> #of borings ❑Geotechnical of borings <br /> ❑Monitoring Wells) #of wells 13 Soil Boring(s) <br /> ❑Out-Of Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum Pum Replacement ❑Pump Repair (� <br /> WELL ONSTRU N <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter Cl Open Bottom ❑Gravel Pack 1 Gravel Size in diameter 10 <br /> ❑Conductor Casing -- in diametcr 1 Conductor Casing Depth ft <br /> Well Casing Diameter in ThicknesslGaugdASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Sea[ Depth ft ❑Neat Cement(941b bag 15-10 gat water) ❑Sand Cement sack mix!7 gal water <br /> C7 Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑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 /> 1 HEREBY CE 1FY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUfN CO NTY 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 /> M1N[M 4 H UR AD ANCE NOTICE UIRED FOR INSPECTIONS ff <br /> SIGNED TTTL Y - DATE �✓ <br /> 4 <br /> I <br /> it <br /> I <br /> � A <br /> u <br /> D�ErP-A.R,T M_E-NT--U_S-E­O-N-L:3(_� <br /> Application Accepted By r�.� Area Employee ID# 7 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit 7 <br /> I <br /> l Pump Inspection By Date — 7 `,tAQ_ ❑ WAIVER Received <br /> 1 Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Che Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Reguest# Invoice# well <br /> t <br /> EHD 43.02.006 WELL PUMP PERMIT <br /> 1/27/2005 <br />