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WELL 1 PUMP PERMIT L 6°S_ya g <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 384 E WEBER AVE 3R°FL-STOCKTON CA 95202 - (209)468-3420 <br /> l NON-REFUNDABLE PERMIT CALL 209 953-7097 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> CITIZPrJOB ADDRESS <br /> > <br /> CROSS STREET X6 4 1 I-V*e APN 1 ! `0 Or�0 _0 PARCEL SIZEez-0—tILLAND USE APPLICATION# <br /> OWNER NAME /—r�gg / rWt PHONE <br /> OWNERADDRESS b4 S• 1✓161 CITYISTATEIZIP 41*Arg64 <br /> © � � ���y <br /> CONTRACTOR /Vel . ( PHONE �'l --;07^--?7 0/ <br /> I CONTRACTOR ADDRESS % y rI G�U.��Y�G'{ G[�� CITYISTATE/Z1P z7iC!, C1 %fd V0 <br /> SUBCONTRACTOR S PHONE G` <br /> SUBCONTRACTOR ADDRESS CITYISTAZt �a <br /> 0 <br /> LICENSE )VC-57 13C-61 ❑D-09 Q Other NUMBEREN <br /> e HNALTNA T <br /> H_E <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y ftVMiR an a ectio _ <br /> INTENDED USE ❑Domestic/Private C]irrigation/Agricultural ❑Industrial ❑Water Quality Mo�A tonng of amp t a <br /> ❑Public Water System w�rbell eom Peted or inspecled <br /> iVdifferent from Owner: Water System Name Co tact m <br /> III <br /> TYPE OF WORK ❑New Well ❑Replacement-Well ❑Well Alteration/Modification ❑Other <br /> F <br /> ❑Monitoring Well(s) #of wells 13 Soil Boring #of borings s} J54Geotechnpf boringsi l <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary WAuger ❑Cable Tool ❑Push Point ❑Other Zj <br /> Proposed Well Depth 0^11- ft Excava n & in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> ❑Conductor Casing in ameter / Conductor Casing Depth ft <br /> Well Casing Diameter in TZFFaIl <br /> Gaug ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth Nea ement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water `] <br /> ❑Bentonite(20%solidnufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Other` ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> i ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set R Standing Water Level ft <br /> I HEREBY CERTIFY THAT I RAVE 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. <br /> MINIOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE DATEfl <br /> D <br /> I <br /> I <br /> Al <br /> Lp <br /> T <br /> P0 3 13 <br /> _A 1 <br /> 1R <br /> .. .. . �, ,DEPARTMENT ,USE.$-O N L Y <br /> Application Accepted By , Date �" Area Employee ID# (4000 /J <br /> Grout Inspection By Date a d ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed WelLpepth ft <br /> COMMENTS ) <br /> c ►+ +Nk.� <br /> PE SC Received Check# Amount Date Permit! Invoice# WeI11D# <br /> Codes Info B ash Remitted rvice Request# <br /> �� 5 D� `°j7 003376, <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/2712005 <br /> 4 <br />