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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3Y"FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS FXPIRES 1 YEAR FROM DATE ISSUED <br /> lm <br /> JOB ADDRESS CITY/ZIP 5D <br /> O <br /> CROSS STREET LL APN 1101-407(0-340 PARCEL SIZE LAND USE APPLICATION# z <br /> n <br /> OWNER NAME, r YA E.ONT'ERADDRESS CITY/ST'ATE/Z11HION <br /> t :2210CONTRACTOR , HOtiE " - _1�t� <br /> CONTRACTOR ADDRESS IL7K <.Jdr CITY/STATE/?-P ��� /r•-7Lr/ � / �� O <br /> SUBCONTRACTOR PHONE IN 14 <br /> SUBCONTRACTOR ADDRESS C YISTATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EKPIRATION DATE <br /> i <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section I e� <br /> INTENDED USE meSUC/Private ❑Irrigation/Agricultunal ❑Industrial O Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System_ <br /> LIf dH7erem from Owner. eter ysttm sme Comiun Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> q o(honn(7 <br /> ❑Monitoring Well(s) #of wells ❑Soil Boringq of honnp <br /> Boring(s) O Geotechnical <br /> ❑Well Destruct, ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ew Pump Y—Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRU ION <br /> Drilling Method O Mud Rotary ❑Air Rotary O Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth It Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> O Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in ThickneWGauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94/h hag/5-10 gal wafer) ❑Sand Cement .suck mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method O Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Dnller ❑Pump Contractor ❑Other <br /> Concrete Pedestal Dimensions: Width R Length ft Thick in ❑Christy Boz ❑Stove Pi <br /> P -' xSubmersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAW'S,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 /> WORKCOMPENSATION LAWS. <br /> NI �4 HO N ADVANCE NOT]C EQCI ED FOR INSPECTIONS <br /> i <br /> SIGNED Trr DATE <br /> V` <br /> 05 <br /> COUP TY <br /> JD= <br /> PRT AETr <br /> o <br /> i <br /> i <br /> I PARTMENTUS/E ONLY <br /> Application Accepted O,p—l(0'i/� Area Employee ID#� :C/ <br /> Grout Inspection By Date ❑ SPECIAL Well Permit /7 <br /> Pump Inspection B61zlle6:1 <br /> - 2= - - Date --3 e Ccs ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS " l��cl _ �l �.L�.4>•„'-pct-- /y/C,�'c- C f�� -�ir �lit/"-2 <br /> 7-k) J <br /> PE SC Received eek#/ AmountPermit/ Invoice# Weil IDN <br /> Codes Info BY Remitted ate Service Request# <br /> 0sv a AO Q6 3-5-43 <br /> EHD 41-02-00� WELL PUMP PERMIT <br /> XW04 <br />