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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 95 7697 FOR INSPECT IONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �jy{,I VC. ^" '�+''"``� '� L (N I IQ(`(j CITY/ZIPC' -mom S�� <br /> CROSS STREET rkl 1 ` C7 APN(Vf7';- �yU"x _.PARCEL SIZE �� LAND USE APPLICATION li � <br /> Y, <br /> F <br /> ` ^I r ? <br /> OWNER NAME T +J ['//(q yI __ PHONE <br /> OWNER ADDRESS (7/-2 Z /y" /�/IDS,! 1 Y 1 f CITY/STATE/ZIP <br /> �A 7T <br /> CONTRACTOR -"--�6*'s J4� +^t II I Vf 9 PHONE <br /> CONTRACTOR ADDRESS I ` ( K�PvCITY/STA-FF/ZIP -� <br /> / <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEJZIP /'f 7 <br /> LICENSE -57 ❑C-61 ❑D-09 ❑Other NVMBE Z EXPIRATION DATE��L'`f <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE ❑Domestic/Private rrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterintion <br /> ❑Public Water System <br /> If ditTerent from Ow —r ymin — me°r one u <br /> TYPE OF WORK O New Well Replacement Well ❑Well Alteration/Modification ❑Other 14 <br /> lJU'` <br /> 6, M of Bonn <br /> ❑Monitoring WCII(S) #of wells 1)Soil Boring(s) s°f bone ❑Geotechnical g' <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Conncction Repair <br /> ❑New Pum ❑Plump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method*ud Rotary ❑Air Rotary ❑Auger ❑Cable Too) ❑Push Point ❑Other <br /> Proposed Well Depth-q.20—III Excavation__e• _-in diameter ❑Open Bonom Gravel Pack/Gravel Size in diameter <br /> ❑Conductor C ing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter m Thickness/GaugdASTM Sched V Nteel ❑Plastic ❑Stainle�sts-7Steel ❑Other <br /> Grout Seal Dcpth ft 11 Neat Cement(94(h Aag/S-/0 gol wafer) ❑Sand Cement 1/I--4�1 sack mix/7 gal water <br /> ❑Bentonite(20"/6 solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement MethodPumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Dnllerump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length tl Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level it <br /> 1 HEREBY CERTIFY THAT 1 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. 1 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 /> �^ MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> V111 <br /> SIGNED Y 1 C.i CL TITLE 1 JNt t P/�N DATE <br /> A JCAC Ad C6Ui,ITyj <br /> N A <br /> — r <br /> w " <br /> 11 <br /> � 10 <br /> u q <br /> EP RTMENT SE ONLY //�� Ila I <br /> Application Accepte Date I Area Employee IDN;�_ <br /> Grout Inspection Date y.Qd 57 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth It <br /> COMMENTS 5 C47 UCAlk 16&91, -rO 100—r- VIA <br /> s <br /> PE SC Received CheclDi/ Amount Date Permit/ Invoice# WellID# <br /> Codes Info B as Remitted Service R nest# <br /> ,,U02 7N' <br /> WELL PUMP PERMIT <br /> EHD 47-01-006 <br /> 1/27/2005 <br />