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WELL/PUMP PERMIT //1-1 L 61329.GOS <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3`°FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIOSN a3 EXPIRES ( � <br /> 1 YEAR FROM DATE ISSUED <br /> +,Joe ADDRESS �MDwt/� 1/► p�rM1 '""j crrvaiP HDUeil6a e <br /> 1 � <br /> PARCEL SIZE AND USE APPLICATION# <br /> CROSS STREET ' !"I I.(, Y 1✓Y'� APIC._ <br /> OWNERNAME e.0 Z L4:-- PHONE rn <br /> OWNERADDRESS /+ f� [1 CITY/STATE/ZIP <br /> fCONTRACTOR k I ✓1 C PHONE/?Q6 <br /> � <br /> CONTRACTOR ADDRESS 4�y } �(�r �--{a-�� _ CITY/STATE/ZIP C c R f a n C�.LJ <br /> PHONE <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS CTI ISTATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Othtt NUMBER4&72,,,�EXPIRATION DATE Q-60 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System erer yrtem cmc tact arae or one Number <br /> If different from vmer. <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification a of❑Other a of boring <br /> ❑Monitoring Well(S) #of wells ❑Soil Bonng(s) ss Geotechnical—�_ <br /> ❑Out-0f-Service Well ❑Out-O&Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> Wgt.l.CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary (Auger / ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth, �ft Excavation_Lilt 4��_ 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 ft ❑Neat Cement(94 th bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(2(%solids) ❑Manufacturer Spec%solids % Named_b�1.Lw rot,If Specs on File SO Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(na e) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width it Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT 1 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. 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 COMPENSATION LAWS. <br /> MINIMU 24 UR ADVANCE NOTICE RREEQQUUIIRE(y/]�)FO�Rr INSPECTI( S <br /> SIGNED TITLE�VXriT 1/[1r � /��"� DATE / J ©V <br /> SA J I UI O <br /> DEP RTMENT SELONLY ���� <br /> Application Accepted By Date v Area Employee ID# <br /> Grout Inspection By Date W&ir- ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS /pert% Jf ra W C- JIIf ((V1 &2tr <br /> PE SC Received Check# Amount Permit/ Invoice# W1 ID# <br /> Codes Info B as Remitted <br /> Date Service R uest# <br /> 2 S� Vi C- 12 t'' D6 S eo � (can <br /> WELL PIJMP PERMIT <br /> EHD 43-02-006 <br /> 1127/2005 <br />