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1 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIy COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 -(209)469-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> r y <br /> ,Z�Z US, S 4 /1 ; � <br /> JOB ADDRESS GLJ T/•CITY/Zip <br /> CROSS STREET C APN.ZZ�-7�.5 O:��ARCEL SIZF� LAND USE APPLICATION# tv <br /> OWNER NAME Fr�c PA I/'�krS,.,,l/ �Vn�i(�J`/ TSS Ala✓SPV•� � P�HpONE�/�� L / P�/ <br /> OWNER ADDRESS 23- S� //LL-/1/Tl�ri"—&• CITY/STATE/ZIP �iY�Y'l `-aJ- �✓�.�G.0 <br /> CONTRACTOR I I .I q/I14s I�js PHONE— <br /> f-22— //pJ <br /> CONTRACTOR ADDRESS CITY/STATFIZIP /I(LL7 <br /> jeS10F 21 <br /> SUBCONTRACTOR PRONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP � <br /> LICENSE WC-57 ❑C-61 ❑D-09 ❑Other NUMBERQ L EXPIRATION DATE 2-e- /j <br /> GEOGRAPHICAL INFORMATION: Coordinates X V 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 er eta yrtem erne Contact Name or Phone Number ^r <br /> TYPE OF WORK( flew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other v <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) Nofborings ❑Geotechnical kofborings <br /> ❑Out-0f-Service Well ❑OutOf--Service Well Renewal ❑Cross-Connection Repair N <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair 1 <br /> WELL CONSTRUCTION ^ <br /> Drilling Method jXkAud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other V Ir <br /> Proposed Well Depth 220 ft Excavation l in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conducto sing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 0 In Thickness/Gauge/ASTM Sched 1.P' `'' ❑Steel 04lastic O Stainless Steel ❑Other <br /> r <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack m&/7 gal water <br /> gBBentonile(20e/solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method Cill!junped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> r\ <br /> PEDESTAL Installed By ❑Driller mp Contractor ❑ Other !� <br /> ❑Concrete Pedestal Dimensions:Width It Length ft Thick in ❑Christy Box ❑Stove Pipe v <br /> puMP ❑Submersible ❑Turbine ❑Other HP Pump Set fl Standing Water Level R <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN f <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 /> MIINII�MGU 24 HOUR ADVANCE NOTICE <br /> `REgU[RED FOR INSPECTIONS <br /> SIGNED L)c 7t��J <br /> C. l�r`�t� t�L TITLE SY� IK✓t DATE <br /> v <br /> 1 11111L I <br /> P-1- <br /> - 1 <br /> ZL <br /> a. <br /> r <br /> E RTMENT US O LY <br /> Application Accepted By to Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit / <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ AmountDate Permit/ Invoice# Well IDM <br /> Codes Info as Remitted Set-vigpitequest# <br /> ylkq /9C, W 1,1/ Z tvP4 r i b SZ� <br /> END 43-0.006 WELL PUMP PERMIT <br /> 11!72005 <br />