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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 30a FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / Z2Z �US f l`r \ CITY/ZIPR�nr� —, <br /> m <br /> -�-,� --Z6- 15-0-Z7 �7� °o <br /> CROSS STREET C APN PARCEL SIZE LAND USE A�PPL�LC�A'1TION# 7? <br /> OWNER NAME -7 rear-1 �] wY�C�iYUs PHON(gc 59991- Z91t0 `•' <br /> OWNERADDREss /-:,; S ��A..S�I I� CITY/STATE/ZIP�ISS(--3() <br /> CONTRACTOR AZAS II LL�� r- I =n( PHONF'.n�( ) 577-3�l.Sh <br /> CONTRACTOR ADDRESS `cJ ( CITY/STATE/ZIP R-i(�OI\ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS hh CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 Other, l.J NUMBER& ar-3 -Z— EXPIRATION DATE O <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ofoomesticlPrivate Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characteri2ation <br /> ❑Public Water System <br /> Ifdifferentfrom Owner: Water System Name Contact Name or one um r <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #ofwells ❑Soil Boring(s) sof borings ❑Geotechnical not borings <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 ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth It Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sizein diameter ✓" <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth B ❑Neat Cement(94/b bag/S-/0 gal water) ❑Sand Cement sack mix/7 gal water ✓� <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Platenxnl Method ❑Pumped ❑Free,Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width It Length R Thick in ❑Christy Boz ❑Stove Pipe <br /> h <br /> PUMP Submersible ❑Turbine ❑Othcr HP Pump Set fl Standing Water Level fl \' <br /> 1 HEREBY CE IFY 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 CERTIFY THAT MY REQUIRED LICENSE IS ( - <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEN ON LAWS. <br /> M11. M 2 HOUR A ANCE NOTICE <br /> /13JiQU1RED FOR INSPECTIONS <br /> TITLE <br /> SIGNED _ / r <br /> SIGNED of DATE <br /> NIR N ET <br /> / / DEPARTMENT USE ONLY <br /> Application Accepted By z, Date U �l Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By LI `^'� Date 1Y 17 ❑ WAIVER Received <br /> Constructed WellRypth ft <br /> COMMENTS �/1 � <br /> PE SC Received Chec Amount Date Permit) Invoice# Well11D# <br /> Codes Info B ash Remitted Service Request# <br /> 4f/ <br /> EMD 43-02-006 WELL PUMP PERMIT <br /> 1/272005 <br />