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ELL A PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHARTMENT 304 E WEBER VE 3a° FL - STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT U) A-L7L 209 9h3-7697 FOR INSPECTIONS EXPIRES I YEAR FROM BATE ISSUED <br />JOB ADDRESS 1��— v 1 N — — — -- CITY/ZIP <br />CROSS STREET C! 1�'4✓ i`A®PN 'W106001 PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME i (J� V 1 N'G PHONE <br />OWNER ADDRESS J� lD q�' j� , V( � �J -_ ^ _ CITY/STATE/ZIP _ "CC.' -j <br />CONTRACTOR I\� CZ) N � 1 � V CT 1 Q ° ,0 L PHONE: �®^( � �/� <br />CONTRACTOR ADDRESS !-� %�. Qt<--,- & CITY/STATE/ZIP �1'q jVtgJN }✓ I C� <br />SUBCONTRACTOR N/ 6®r PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE &C-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP <br />NUMBERO 5 < EXPIRATION <br />IFJFAM <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 <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification X Other <br />Monitoring Weil(s) '2— # of wells ❑ Soil Boring(s) # of orings ❑ 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 Rotary it Rotary ❑ Auger�t,I` ❑ Cable Tool ❑ Push Point ❑ Other" <br />Proposed Well Depth ft Excavation CJ in diameter ❑ Open Bottom Gravel Pack / Gravel Size in 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 De th A(�I/?,t)1 ft ❑ Neat Cement (94 lb bug 15-10 gal water) ❑ Sand Cement suck 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 ❑ Driller ❑ 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 It Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TjjiAT 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 CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS CO ATION LAWS. <br />IMU HOUR ADVANCE NOTICE REQ I ED FOR/rINPECTIONS <br />SIGNED TITLE _. `//'C.. ��/V (J\ DATE !J <br />DEPARTMENT USE ONLY <br />Application Accepted ByQ `"""' Date 1 i3 Area Employee ID# ?a , <br />Grout Inspection By C Date O AV d ❑ SPECIAL Well Permit <br />Pump Inspection Date ❑ WAIVER Received <br />Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC Received <br />Info By <br />Check�#// <br />Amount Permit/ <br />Remitted Date Service Request # <br />Invoice # <br />Well ID# <br />J(f —j` <br />END 43-02-006 WELL PUMP PERMIT <br />1/27/2005 <br />