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?70 <br /> ��,' <br /> w ��.. WELL / PUMP PERMIT <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 INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> L2 <br /> Ait �� /✓�'1 1 J l�l_J r 1 c, CITY/ZIP <br /> JOB ADDRESS � y <br /> CROSS STREET APN 12,0-C>9 PARCEL SIZE Lo LAND USE APPLICATION# <br /> OWNER NAME ���-L FA M(L_'1 <br /> _ CrWCP(C5 IG PHONE <br /> OWNER ADDRESS 2 ©D w` CITY/STATE/ZIP A <br /> (A '�"/S Z-0 4 <br /> CONTRACTOR 061C 0+ `/'St ! I N PHONE c'{ �j^{ <br /> CONTRACTOR ADDRESS 102, �/+/L/�l�( �L �, li""f 1 CITY/STATE/ZIP LD o1, ( 4 2 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS /CI,T/Y/S�TjATE/ZIIP Of�( <br /> LICENSE ((C-57 ❑C-61 ❑D-09 ❑Other NUMBER 69&I00 4 EXPIRATION DATE C/ ( P Q <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 ❑Other { <br /> ❑Monitoring Well(s) #of wells Soil Boring(s)(_ #of borings ❑Geotechnical #of borings �jl <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 ft Excavation (0 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 Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> F <br /> ❑ entonrte�0%solids) ❑Manufacturer Spec%solids % Name � (l_ (.f)�to,3 j Ir. ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method��O 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 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 CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS c� <br /> SIGNEDZTITLE 1 �-1 fi RC ( <br /> R. DATE 7-/-U(' <br /> Ave <br /> �U(;BT1t6 � <br /> ,AI Rose st, <br /> P+xtes m mopd pve <br /> c Ray <br /> W p p ria C? <br /> `-•, vim. <br /> p,ablo pye l 4caeja ct <br /> Mopte <br /> phorate N D1abti0 Ave pGycta Bt <br /> 7, WI <br /> f { <br /> CP <br /> SAN 7y 77 R9 r1C U�Ty <br /> Al_ <br /> RT vi•ENT <br /> 4:F1 <br /> -Pp TMENT US ONLY - _— — <br /> Application Accepted By Date Area Employee ID / <br /> ��6roe:t Inspection B �` Date & l v ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check# Amount Permit/ <br /> Codes Info By as emitted Date Service Request# Invoice# WeI11D# <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/27/2005 <br />