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- WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3 R FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7097 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> � j �l �` tri 2 //�� A / � <br /> JOB ADDRESS 2—L4� 1 `o or n I 1 ex 1_���C� CITY/ZIP S� , \ e y-t ��lf� <br /> ��' ' i )r� � d <br /> CROSS STREET L_ 4—Q�rot� APN O)-*'1't C3 Z� _� �PARCEL SIZE 6�_ LAND USE APPLICATION# <br /> Pic �s < �c�S i _ 0 7 K <br /> OWNER NAME � � � Z ( C ���� PHON� ��� � ��' V°� /� /�Q <br /> OWNER ADDRESS `^�/5 �NC?��,1h j _ -J 1 � T,/STATE/ZIP ^ VC,..) <br /> CONTRACTOR s' V A--s) _L ► �A�/GCS 1lJY 1 / �I�C PHOONN�nn q g:/1y <br /> CONTRACTOR ADDRESS 1 "IQ,I r t CITY/STATE/ZIP� �, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS j (C'I'TY/STATE/ZIP '7 <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 Other - I U NUMBER(O(oZ-7 2 EXPIRATION DATE / <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/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 <br /> ❑Out-Of-Service al ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pump 4FLumpReplacement ❑Pump Repair <br /> WELL CONSTRUCTION C► R <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter C, <br /> ❑Conductor Casing in diameter / Conductor Casing Depth 11 C <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 /> ❑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 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 W <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 COMPENS ON LAWS. ,N <br /> MINI M 2, HOUR VANCE NOTICE R UIRED FOR INSPECTIONS /l <br /> SIGNED n TITLE! �� D t? <br /> 1E THA H <br /> P�R / R I E <br /> Ait Cti, <br /> L-AIn SN OQIN ON ry <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 11 [2_240b Area Employee ID# qS C t / <br /> Grout Inspection By Date 11 SPECIAL Well Permit / <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth It <br /> COMMENTS &9!%;o 0/z 3d � <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted © Service Request# <br /> 9 �_-,C% <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/27/2005 <br />