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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 95202-(209)"B-3420 <br /> • NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> Q p,�P,,/ n y <br /> JOB ADDRESS 2-41714 C 6 rIl V 1 -( X CITY/ZEP <br /> • CROSS STREET Lo K`•� ,1u ^M pPN OJ 1 9� Q I PARCEL SIZE 3 15 LAND USE APPLICATION!! _9Oe <br /> OWNERNAME K(2- C fl 1� rl I l%rZ I ` PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> S4 teemTRKrT"IFJ oW �i114 E PHONE 7-63 O �61 <br /> f� <br /> CONTRACTOR ADDRESS 1 020 �'4a•Ir SJi (C Crry/STATE2QEp o'1li-L-ftf�/) �'lyY/6oa <br /> SUBCONTRACTOR l r'1 R C�2 �11�So PHONE �� IG 7 ? It <br /> ! l� t7 <br /> SUBCONTRACTOR ADDRESS 3 +11 WtLS I e-Ap( IQL- 1'I/�J• CrrV/STATE/LEP�LSS(-f ) Cr470 9$61) <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER "6"o EXPIRATION DATE 1110S <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Rangt Section_ <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Wmer Symern N.. Contact Name w Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) k of wells Soil Boring(s) t of bongs ❑Geotechnical x of boring, Iry <br /> ❑Out-Of-Service Well ❑Out-Of-Swice We I Renewal ❑Cross-Connection Repair "+`•. <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ^1 <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other •J <br /> Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter�hin Thickness/Pauge/ASTM Sched QnSteel ❑Plastic ❑Stainless Steel ❑Other e\ <br /> Grout Seal Depth fl 11,Veat Cement(94 1b bag,5-10 gal wafer)4T 6�Sand Cement sack mix/7 gal water <br /> ❑Bentonite(201/.solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) O GKTTZr�CrS. <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other �- <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Bos ❑Stove Pipe <br /> PUIITP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level fl <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. i <br /> MI Nt 11 "A1 24 HOUR ADVANCE NOTICEDp REQUIRED FOR INSPECTIONS -f p <br /> SIGNED TITLE `�-C)��u mAtJ�Vt✓`t2 DATE <br /> PAYMENT <br /> RECEIVED <br /> JUL 2 6 2005 <br /> N JOAQUIN COUNTY <br /> �g­ ENVIRONMENTAL <br /> EALTH DEPARTMENT <br /> DEPARTMENT U E ONLY y <br /> Application Accepted By Date 7 S Area Employee IDk 3 6 4 f <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth R <br /> COMMENTS <br /> PE SC ReceivedCheck#/ Amount Date Permit/ Invoice q "'ell IDN <br /> Codes Info B Remitted Service Request p <br /> 7 t5023 0•c/l� Q <br /> EIID43-014q6 <br /> WELL PUMP PERMIT <br /> 1/272005 <br />