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lv,�-rL O GELL-/PUMP PERMIT SCANNED <br /> ;AN JOAQUIN COUNTY ENVIRONSIENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> F <br /> IOB ADDRESS / :) CITY/ZIP �% <br /> Lc <br /> :ROSS STREET•' APN C4•7— 2-G-C-('7 PARCELSIZL` LAND USE APPLICATION i/ <br /> OWNER NAME. .�.rl.. ` "!•,. '! PHONE <br /> 3WNER ADDRESS �1'��'r CITY/STATE/ZIP <br /> CONTRACTOR � � J - \ �/'.; r�T`,' +' PH <br /> CONTRACTOR ADDRF..SS ! / `' ' CITYISTATE/ZIP <br /> IUBCONTRACTOR <br /> f� ' PHONE ' <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> 'ACENSE .:❑iZ-57 ❑C-61 ❑D-09 ❑Other NUMBER -�,1.1'u EXPIRATION DATE <br /> :F.OGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> TENDEDUSF ,.-C.Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If di raitm tram Owner: Water System Name onuUName or Phone Number <br /> 'YPE OF WORK.t3 New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) N of wells ❑Soil Boring(s) M tf borings ❑Geotechnical a ofborings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ,New Pump ❑Pump Replacement ❑Pump Repair <br /> VELL CONSTRUCTION f� <br /> )rilling Method-,"D Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other t <br /> Proposed Well Depth-165—­ft R Excavation //T_in diameter ❑Open Bottom ;QGravel Pack/Gravel Size Orr— in diameter <br /> ,� <br /> ❑Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter / in Thickness/Gauge/ASTM Sched ❑Steel ;Z'Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ./ ft ❑Neat Cement(94 111 bag/5-10 gal water) -e&Sand Cement /�✓ —` sock mix 17 gal water <br /> ❑Bentonite(201/6 solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method -M?umped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) r� <br /> 'EDESTAL Installed By -CFDriller ❑Pump Contractor ❑ Other C <br /> ❑Concrete Pedestal Dimensions:Width ft Length R Thick in ❑Christy Box ❑Stove Pipe r <br /> PUMP CISubmersible ❑Turbine ❑Othcr NP Pump Seth''' L: R Standing Water Level R <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> IOAQUIN COUNTY ORDINANCES,STATE LAWS. AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> "URRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> NORKERS COMPENSATION LAWS. <br /> IININIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS L <br /> i1CNEU / ,/ TITLE tFl i/f..,sr'•.. DATE <br /> 5 <br /> Ile <br /> 'Z <br /> I <br /> I I <br /> V I ) <br /> I — <br /> V <br /> ii Tit j UIt G <br /> _ __ _ NIR -M N1 <br /> v. ro DEPARTMENT USE ONLY �l <br /> Application Accepted By. Date —7 IS (•'S Area Employee ID# <br /> Grout Inspection By 1\ Date ZC d 13 SPECIAL Well Permit <br /> Pump Inspection By, i�. � •' ( � Date S—PJ—6 ❑ WAIVER Received <br /> Constructed Well Depth 13ft <br /> COMM ENTSS�r1'Ntr 9ti jsC—s� 7S <br /> r <br /> PE SC Received Chec Amount Date Permit/ Invoice0 WellIDN <br /> Codes Info B Cash Remitted Service Request N <br /> �3 is i(-I -&(— 7 0-7 -,�.c ;o I i—oS 1"LO l - , <br /> END 43-02-006 WELL PUMP PERMIT <br /> 1/27!2005 <br />