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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3'"PL-STOCKTON CA 95202 - (209)4IM-3420 <br /> NON-REFUNDABLE PERMIT II CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS Jr r ��I"'� `� per-[/. CITY/ZIP f }hjk'JaeL1 <br /> '�7 O <br /> CROSS%-rRF.ET_jAj} IC <br /> �x ��_ APN Q r //PARCEL SIZE��LAND 1'SE APPLICATION# <br /> —T —s ''7 1G <br /> OWNER NAME A/1/I�/I/l X4 _----_ _� PHONE 20-01—`Z� <br /> OWNER ADDRESS In�� c%,.,4 r. _ ! CITY/STATE/ZIP <br /> CONTRACTORPHONE �r�-q <br /> r <br /> CONTRACTOR ADDRESS n ^^ CITY/STA'rE/ZIP <br /> SUBCONTRACTOR IIIy PHONF <br /> SUBCONTRACTOR ADDRESS JI CITY/STATE/ZIP <br /> LICENSE C•57 ❑C-61D-09 ❑Other NUMBER ExPIRA'rio.s DATE <br /> H <br /> GEOCRAPIIICAL INFORMATION: Coordinates X Y Township RanKc Section <br /> INTENDED USE ❑Domestic/Private t�[ ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring oil SamplingiCharacterization <br /> ❑Public Water System! <br /> Vdifferent Cram Ownet: W&tct Systern Name ContAtl NFuna or Rvone Number <br /> it <br /> TYPF.OP WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ' 0 of borings p oCbonngs <br /> ❑Monitoring Well(s) 0 of wells ❑Soil Boring(s) M� ieotechnical _ <br /> ❑Out-Of-Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection.Repair - <br /> ❑New Pump 0Pump Replacement ❑Pump Repair <br /> WELLCONS-rRUCI'ION III J <br /> 4 ' <br /> Drilling Method 11 Mud Rotary ❑Air Rotary Qby4uger ❑Cable Tool ❑Push Point ❑Other � <br /> Proposed Well Depth f1 Excavation S4 1/2- in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing II in diameter 1 Conductor Casing Depth fl <br /> Well Casing Diameter in Thicknes&,Gaugc/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 11 tt ❑Ncat Cement(94 lh hag 15-10 gal water) ❑Sand Cem nt_—� C rack mu/7 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 <br /> ❑Concrete Pedestal I Dimensions:Width ft Length fl Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set fl Standing Water Level R <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATIO <br /> INIMUM 24 HOU ADVANCE NOTICE REQ D FOR INSPECTIONS (� <br /> SIGNED t TITLE DATE , <br /> p <br /> �r <br /> II <br /> II <br /> II <br /> li <br /> I <br /> :IG <br /> tlf. <br /> II � <br /> II. <br /> II <br /> dl <br /> II <br /> 37 <br /> IA <br /> II <br /> Iful Urt <br /> i N JIR N <br /> III <br /> II <br /> E-P A R-T M•E-N'T—u Si;-O- <br /> �plication Accepted By d _ Dale � 0� Arca Employee I <br /> spection y- _- - Dale ❑ SPECIAL Well Permit <br /> Pump Inspection By �I. Date 0 WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS WZ;O Ci�j ZL'A69- <br /> PE <br /> l»PE SC Received it Check#1 Date Amount Permit/ Invoice ft Well IDlI <br /> Codes Into B I Ca—sh Remitted Service Request# <br /> - 1- 0 s4 1y I bn R'00 '+9—7 05' <br /> II <br /> II <br /> I.. <br /> E)lD 0-02-006 1. WELL PUMP PERNI'C <br /> I.Qtf2005 <br /> I <br />