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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (109)468-3410 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z"'L /� F CILIP r 1 S V <br /> CROSS STREET V O jI C4-re_>A 4_ APN 16E- 2-A0-V(p PARCEL SIZE I r Z'LAND USE APPLICATION# A <br /> OWNERNAME OFF1}tQI�C6N ( A,PHONE � <br /> OWNER ADDRESS CITYISTATEIZIP <br /> CONTRACTOR _..�I �_'- A2!4 z__ Vb^j A J SC�Lr'^+-e�r�f���,S— PHONE 24ri- 7?.r-:Y 3�Fp <br /> CONTRACTOR ADDRESS Du s � _ �/ -_ CITYISTATEIZIP Loor ti <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE jC-57 ❑C-61 ❑D-09 ❑Other NUMBER dClo_l` 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: ater ystem Natne Contact Name°r P one Num r 4— <br /> TYPE OF WORK 0 New Well ❑Replacement Well ❑Well Alteration/Modification t rri <br /> ❑Monitoring Well(s) #of wells Soil Boring(s) �!°fbori <br /> ❑ C <br /> Out-Of-Service Well e ❑Out-Of Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pum Repair PittV <br /> W6x fired without <br /> � + <br /> WELL CONSTRUCIION �,rWDC being completed or Inspected <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Augcr ❑Cable ToolP-,,, ren m O <br /> Proposed Well Depth _ft Excavationin diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth 11 <br /> Well Casing Diameter in ThickncWGaugeIASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941b bag/5-10 gal water) ❑Sand Cement sack prix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name So* ` L3 Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped OF=Fall ❑Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ t <br /> ❑Concrete Pedestal Dimensions:Width gt ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 1 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS � <br /> SIGNED -.- TITLE �'�'r 1 F Y+ya�,/VE�Q DATE <br /> • � i �K �� ,p i --�-r�l--I—i� <br /> i <br /> a <br /> ry- A <br /> - <br /> IWA <br /> r : <br /> !11 <br /> 1v V HL N NA i <br /> DEPARTMENT USE ONLY - _�_.0� <br /> Application Accepted By Date aJ r O(D Area Employee IDN <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well De th ft <br /> COMMENTS - is QvtCpy� �r� f{ rv �C t7'� <br /> PE SC Received rClieciclI Amount Permit/ <br /> Codes Info B s Remitted Date Service R uest# In oice# Well ID# <br /> +372 t G'a iA a 69 o — s QS- <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/27/2005 <br />