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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE <br /> 7PERMIT <br /> '� 2 CALL 2/09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE <br /> ISSUED <br /> Jon ADDRESS / �2- -.._J S R�S�`I \ CITY/ZIP (��l_LTI� ���UYJ 3, <br /> CROSSSTREET \/ 1yIIY)� APN `1'7-6` 1556--Z7PA11EL SIZE-1'79 LAND LAND(USE APPLICATION# A <br /> OWNER NAME -�r��c�rc.S / V/ Y,��� N PHON -Z A S�9/9'1- Z9bo <br /> CI <br /> OWNER ADDRESS 7- I ,/ r l y <br /> lS 1 I Il CITY/STATF,/ZIP ��yY��S <br /> CONTRACTOR r ._�.V> PHONI( 577- ���� <br /> CONTRACTOR ADDRESS 1 1 CITY/STATF/ZIP R it201' (p <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS Cr1Y/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 Other V NUMBER U.233-Z— EXPIRATION DATE C)X Al <br /> GEOGRAPHICALINFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE mestic/Private Irrigation/Agricultumi ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterizauon <br /> ❑Public Water System <br /> Ndifferent from Owner: ater ystem amc onu<t une or one u <br /> TYPE OP WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Momtonng Well(s) #of wells ❑Soil Boring(s) s ufbonnp ❑Geotechnical M of b—rp <br /> ❑Out-0f-Service Well ❑Out-Of-Scrvice Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sizcin diameter <br /> O Conductor Casing in diameter / Conductor Casing Depth fl <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth R ❑Neat Cement(94 lb bag/5-10 gal wafer) ❑Sand Cement sack mix/7 gal water ✓� <br /> ❑Bentonite(201/6 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 <br /> ❑Concrete Pedestal Dimensions:Wldth ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ti `i <br /> I HEREBY CERiIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN J <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 COMPEN ON LAWS. <br /> MINI. M2 HOUR A ANCE NOTICE/ l:[RED FOR INSPECTIONS <br /> SIGNED DATE <br /> I F1 <br /> LL <br /> N IR N E T <br /> DEPARTMENT USE ONLY S• . <br /> Application Accepted By 'X. Date /O 2 /V& Area Employee ID# /c_ <br /> Grout Inspection By // Date ❑ SPECIAL Well Permit <br /> Pump Inspection By /'W';4-4V'./4-4V'./x" Date 3 '7 ❑ WAIVER Received <br /> Constructed Well pth / ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well IDN <br /> Codes Info B ash Remitted Service Request# <br /> '{ -ft GSc I Sn ti ' <br /> EHD 41-01-006 WELL PUMP PERMIT <br /> 1/2712005 <br />