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kAVELL / PUMP PERMITZAJ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPENT a L-STOCKTON C202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR IRES 1 YEAR FROM DATE ISSUED <br /> 3,08 ADDRESS 1 1 t/`0s'+4Ae no arm, <br /> I /L z.l CI .�/ / C/�?. <br /> CROSS STREET ARN ` PARCEL SIZE (+ LAND USE APPLICATION# <br /> OWNER NAME `v p NVIRONMENT HEALTH <br /> 1 �� '� l � PHONE 1 / <br /> 1� ,' 7 <br /> OWNER ADDRESS SIC <br /> v — CITY/STATE/ZIP ' <br /> CONTRACTOR y 1 9" PHONE 2 ! i <br /> CONTRACTOR ADDRESS Y :` Y iL25 CITY/STATE/ZIP ' — <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER SL EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial -W1Nater Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ANew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> , fonitoring Well(s)--,2—#of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of 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 R to ❑Alr Rotary q.,, Auger r.�- ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft ExcavatibP tri diameter ❑Open Bottom SrOravel Pack/Gravel Size in diame <br /> ❑Conductor astng in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched 4C ❑Steel Mastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft RrNeat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By JObriller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I 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 CONTRA TORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMENSATION LAWS. <br /> INIM M2 OUR A ANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNEDTITLE ATE <br /> N <br /> , O\ <br /> N 1.0, M N <br /> D P <br />' DEPARTMENT US.E ONLY 9/q <br /> Application Accepted Byly� cu" Date 4.4 06— Area Employee ID# <br /> Grout Inspection By DateTA>5- ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received C CheclqV Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted ervice Request# <br /> 45/4aW 9 q <br /> I `e -1-9 o <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/27/2005 <br />