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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3ND FL-STOCKTON CA 95202 - (209)468-3420 <br /> r <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ..LQ9614 d. OIJt 1 RSi" CITY/ZIP <br /> CROSS STREET J1���/ APN 1(}.yb acLA � <br /> `.I l `�.f�L�� (PARCEL SIZE LAND USE APPLICATION# yp <br /> OWNER NAME �FLAJQA ( At1e.11i PHONE q� dt�_,IG6d <br /> F OWNER ADDRESS 2,?�(] 0&4 GL4j'3 13 LV O" Tr/oo CITYISTATEIZIP AJ 1 Il <br /> CONTRACTOR Ar4O PHONE Z.9 �—3C'-— 3��_ :II <br /> CONTRACTOR ADDRESS q0-7- --C-AJOU S 1(MA I.— b 64 V CITYISTATEIZIP G�,�r+t/ C.4 I <br /> SUBCONTRACTOR PHONE <br /> t <br /> SUBCONTRACTOR ADDRESS C]ITYISTATTE/Z'IP <br /> LICENSE K-57 ❑C-61 ❑D-09 ❑Other NUMBER is�00��{ EXPIRATION DATE <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 ;fish <br /> r <br /> ❑MonitoringWells #of wells Boring(s)__ f borings bori 1 <br /> { ) Soil Horin s eot a, <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal Vgi9nlgepai <br /> ❑New Pum ❑Pum Replacement 13 Pum Repair I-�asC � 2 11M expired without <br /> WELL CONSTRUCTION o <br /> being completed or inspected <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool lbyushd? Oth I I-In21t tr'^inn <br /> Proposed Well Depth _^ ft Excavation �2in diameter ❑Open Bottom ❑Gravel Pack I Gravel Size in diameter <br /> ❑Conductor Casing in diameter 1 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/3-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(201/o solids) ❑Manufacturer Spec%solids % Name SW;/ (es'f-fi nn t ❑Specs on File Cl Specs Submitted <br /> Grout Placement Method ❑Pumped 6F'ree Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By tor <br /> ❑Concrete Pedestal Dimensi � <br /> ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible 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 /> IN UM 24 HOUR ADVANCE NOTICE(REQUIRED FOR INSPECTIONS 5 <br /> SIGNED TITLE TA-PP ��nlC:��a�E� w_ DATE 2- 0 G <br /> .. Ib <br /> ' - <br /> !E <br /> - <br /> - # _ <br /> IRON E T <br /> R H I= � <br /> r <br /> t _ , <br /> AR M E Iv,T US •�L Y — - — --- - _ - �- - -- <br /> Application Accepted By (0� Date y Area Employee ID#, �� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Deptb it <br /> COMMENTS I <br /> a � <br /> PE SC Received ecldfl Amount Dat Permit/ Invoice# Well ID# <br /> Codes Info B as emitted Service Request# <br /> 55 <br /> EHD 43.02.006 WELL PUMP PERMIT <br /> 1127/2005 <br />