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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 PERMIT �JC.A Ll. 209INSPECTIONS_953-7697 FOR EXPIRES I YEAR FROM DATE ISSUED rn <br /> JOB A DDRESS <br /> fs J e /A t s 1 h �-1� CITY/ZEP c E�t I j c S <br /> 021 ZI� L �., ����,�� <br /> • (`�o ( JM N I ApN 7 PARCEL SIZE�LLND USE APPLICATION# <br /> CROSS STREET 1 ` <br /> — -2— <br /> ( PHONE <br /> OWNER NAME <br /> OWNERADDRESS 7 nn^^ � (( [ CITY/STATE(L� // f J /QQ <br /> C'ep SJ`t�NlNC /t``7'' PHONE I 10� Z6U 0L.J1//'61egaJ <br /> opaw <br /> CONTRACTOR ADDRESS 11 O' 1,lT' S J 1 f L CITY/STATEJLB�C KL Fj r` F-\ CA 9 / 6- I <br /> 16 <br /> SUBCONTRACTOR I A LCA' /` 1✓-`N V/VI�1 (� 1 _ iPHONE ✓ 6 � '�( v C� <br /> SUBCONTRACTOR ADDRESS l 1` Vr L� ( C41 N 1 ( 2 L R V C <br /> -II <br /> TY/STA <br /> ^T <br /> IE/ZIP "�/ C M C/•�O ✓S I <br /> LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER 1 6` 7 0 EXPIRATION DATE <br /> GEOGRAPHICALINFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE O Domestic(Private 17 Irrigation/Agricultural O Industrial ❑Water Quality Monitoring oil Sampling/Characteri>ation <br /> ❑Public Water System mt.a .me« < um <br /> If diff—I from 0— nsr .,gem me �\ <br /> W <br /> TYPE OF WORK O New Well ❑Replacement Well ❑Well Alteration/Modification ❑Othera°f bO""p s of b—p <br /> ❑Monitoring Wells) M of wells Soil Boring(s) 1 ❑Geotechnical <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal O Cross-Connection Repair <br /> O New Pump O Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary O Air Rotary ❑Auger ❑Cable Tool ❑Push Point O Other <br /> e`L.5 fl Excavation in diameter O Open Bottom O Gravel Pack/Gravel Sim in diameter <br /> Proposed Well Depth ^ <br /> ❑Conductor Casing in diameter / Conductor Casing Depth <br /> Well Casing Diameter::'V in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic O Stainless Steel ❑Other y <br /> eat Cement(94 Ib hag 5-/0 ga/wanrJ L'���Mnd Er It sock mix/7 gal water <br /> Grout Sol Depth fl (�JJ <br /> O Bentonite(205/6 solids) O Manufacturer Spec%solids_% Name ❑Spe oO File O Specs Submitted <br /> Grout Placement Method O Pumped ❑Frm Fall O Other O Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width fl Length fi Thick in O Christy Boa O Stove Pipe <br /> El <br /> PUMP ❑Submersible O Turbine ❑Other HP Pump Set fl Standing Water Levcl R <br /> 1 HEREBY CERTIFY THAT I 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. 1 ALSO CEATIfY THAT MY REQUIRED LICENSE IS 1 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 11NINI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPF,cTlo,\7s <br /> SIGNED <br /> JVI/tI}{jv/C-�' TITLE P(7.-IksP-Cl MA->JaGE-� DATE <br /> ------------------- <br /> --------------- <br /> PAYMENT <br /> RECEIVED <br /> JUL 2 6 2005 <br /> N JOAQUIN COUNTY <br /> ENVIRONENTAL <br /> M <br /> EALTH DEPARTMENT <br /> 7 DEPARTMENT USE ONLY / <br /> Application Accepted By <br /> .0 Date 7Z �S Area Employee IDM <br /> Grout Inspection By Date 0 ❑ SPECIAL Well Permit <br /> Pump Inspection By <br /> Date ❑ WAIVER Received <br /> Constructed Well Depth R <br /> COMMENTS <br /> PE Sc Received CheckJ! Amount Permit/ Invoice# Well IDN <br /> Codes Info <br /> B Remitted Date Service Request# <br /> 'f3-7 rsv 240 'L!;tv�� a o <br /> WELL PUMP PERNOT <br /> 171D�!n2aM16. <br />