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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3RD FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> m / T✓moi gS �� 7,� <br /> JOB ADDRESS a� � ot� �' �✓f�`� Crry/ZIP a <br /> v <br /> �t�L� T`- �1 An v <br /> CROSS STREET /IIT• ©s a Uy C 5 IAPN O7 3S-100 obi/7 PARCEL SIZE LAND USE APPLICATION# <br /> ��/ d y <br /> OWNERNAME Fv-IIS V�tiAJ /�GX- y PHONE <br /> OWNER ADDRESS 7 /W W. A Imo'T• Oso /T✓` CITY/STATE/ZIP�_�A 9F.376 <br /> CONTRACTOR Ale D /lYl q�'� ��/ft ��n' PHONE3/pvS <br /> CONTRACTOR ADDRESS 7 o Z"����1// V S.t ��1 CITY/STATE/ZIP 4044% e� / '2 <br /> SUBCONTRACTOR s ap—� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STAITF/ZIP <br /> LICENSE C-57 [3C-61 ❑D-09 ❑Other NUMBER ,I� EXPIRATION DATE ?CTV <br /> GEOGRAPHICAL INFORMATION: 'COOrdinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ct <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 C <br /> #of borings Geotechnical / #of borings <br /> ❑Monitoring Well(s) #of wells. 13 Soil Borings) )14 <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 JQ Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth tv-7w ft Excavation 6 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 Depth R ❑Neat Cement(94 Ib bag/5-10 gal water) ❑SandCementsack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name Se�� G u I�' ❑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 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 COMP NSATION LAWS. <br /> MINI OUR ADVANCE NOTICEREQUIREDFOR INSPECTIONS <br /> SIGNED �' TITLE tbN 'ems DATE G//7 O <br /> 11 90 <br /> C <br /> 5 <br /> \1 LIMA 3-11- <br /> NT`( <br /> S NT kL <br /> T D FAT ENT <br /> SE _ N L Y (il <br /> Application Accepted By ' Date b /7 Area Employee ID# <br /> Grout Inspection By ` Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> I /7 2 7 Z3o,tsa p 5 Q ^-7 <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/27/2005 <br />