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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH--eARTMENT 304 E WEBL -'E 3"O FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES l YEAR FRO'st DATE ISSUED <br /> JOB ADDRESS t / V I I CITY/ZIP C f ;A2 <br /> cCROSS STREET 4 °��k '�� APN L(73- /4b- O t PARCEL SIZE "�LAND USE APPLICATION# /'7 OWNER NAME � � P NE OWNER ADDRESS CITY/STATE/ZIP + / 'Ju <br /> cw <br /> CONTRACTOR c+-/ + rte' </`� N� G ✓- <br /> 16 <br /> CONTRACTOR ADDRESS CITY/STATFJZIP <br /> / ` <br /> SUBCONTRACTOR PHONE <br /> SUBCOMI"RACIY)N AUDNY;S$ CITY/STATE./LII' <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 Other NUMBE EXPIRATION DATE L/ <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: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical ,'o"borings <br /> ❑Out-Of-Service Well ❑ ut-Of-Scrvice Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum ❑Pum Replacement Pum Repair <br /> WELL CONSTRUCTION -� <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other 41, <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft n <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 1b hag/5-10 gal water) ❑Sand Cement sack mix/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 Dimensions:Width III Length R Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible Wurbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND JHAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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 Q <br /> WORKERS COMPENSATION LAWS. <br /> 7 MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS n C /• TITLE DATE 7 2.3/0_- _ <br /> SIGNED rrr���� <br /> P <br /> s1 2001 <br /> E.AN JO,O IN C U T <br /> E T <br /> r <br /> DEPARTMENT USE /ONLY c <br /> Application Accepted By - v Date q 2 (� Area Employee ID# S 4�I( ��9 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit (( <br /> Pump Inspectioti$y- Date 4D / ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> :1--eejtz/141 oa'6j 15pi <br /> PESC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> i{ .6-2 usc) 94 Stl•c% 3 0 4O 0�- <br /> / <br /> EHD 41-02-0,16 WELL PUMP PERMIT / <br /> 1/27/2005 . , <br />