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ELL 1 PUMP PERMIT <br /> HEALTH DEPART 'ENT 304E WEBER AVE J, °:Ft.-STOCKTON CA 95202 - (209)468-3420 <br /> N JOAQUIN COUNTY ENVIRONMENTALne <br /> ,ON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I.YEAR FROM DATE ISSUED <br /> • <br /> aSa <br /> 152 L-" <br /> CITYIZIP a <br /> DOttADDRESS �1tAX��h <br /> t CROSS STREET L/' r APN Uf✓3 I_ PARCEL SIZE LAND USE APPLIC iON#° <br /> PHONEf <br /> OWNER NAME <br /> rrI . <br /> ll l <br /> OWNERADDRESS CITYISTATEIZIP -gS'zzo - <br /> V PHONE.— : 1 �A <br /> CONTRACTOR <br /> CITY/STATE/ZIP is <br /> CONTRACTOR ADDRESS _,�)�J.7 ��+ I�.n �•� - y,-y .-`:' 4i <br /> PHONE '��• <br /> SUBCONTRACTOR <br /> CITY/STATEIZIP <br /> SUBCONTRACTOR ADDRESS =rrtfi I3ffft$ ;ta'Sl 1 ' <br /> LICENSE D C-57 ❑C-61 11D-09 ❑Other NUMBER EXPIRATIONIDATE! <br /> :1811 I�, tit Vii.C1�ri <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township ' { .Y ng�, '. Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑industrial ❑Water Quality Monitoring i1dmfpltn /C>�aTractCliZalion R'r <br /> ❑Public Water System ' ' I <br /> If different from Owner. ater ystem acne Contact ante <br /> jImmo �tf1'}p ': tst: <br /> ' TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification 1'0 Test Hole ❑Other.- <br /> ❑Monitoring Well(s) #of wells ❑$oil Boring(s)I ' wofboring []Gtbnt choir 1 ' �1 `'#oTborings �� �,i <br /> ell Destruction ❑Out-Of-Service Well 13 Out-Of-Service Well R6=«� 11,59 <br /> N ❑13 New Pum ❑Pum Replacement [3 Pum R aii r.? <br /> Cross-Connection R 1I.. <br /> WELL CONSTRUCTION I i tit€ICI tII r4 dll:::tl <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point O Other n t : <br /> 1 i 1� ,s ais ate w r- I; <br /> Proposed Well Depth ft Excavation in diameter, ❑Open Bottom ❑Gravel Pac 1 Vd Siy� m diameter <br /> ❑Conductor Casing in diameter I Conductor Casing.Depth _ ft r <br /> Well Casing Diameter in ThickneWGaugeIASTM Shed ❑Steel '❑Plastic ❑Stainless Stee171,' Qt <br /> T. <br /> { Grout Seal Depth ft E2Neat Cement(941h hag/5-10 gal water) '(wand Cement sack mLV!7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name 13:Spt9es'. File ,y ❑Specs Submitted : <br /> 4 Grout Placement Method umped Cl Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed BV ❑Driller ❑Pump Contractor ' ' - ' 13 Other <br /> t �. <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box x ❑Stove,Pipe <br /> 't <br /> a PUMP ❑Submersible ❑Turbine ❑Other ' HP ; Pump Set ft StandinglV ter Level ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL'BE DONE 114q CORDANCE'WITH SAN i <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THX'C2.MY REQUIRED)LICENSE 1S <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AMON,COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. A <br /> UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS, „j•21 iflrjl;l,,t {r <br /> SIGNED - TITLE <br /> - �• 'fid t r .�.,�.`' -' '_' f j, <br /> fypv. J. — +.-1 te• <br /> I J <br /> n. MSE N T <br /> 6 E P A R r 51 �lj•1r / ��t1 [ r. <br /> � -..-...�. �.,. .,,U 8fE ..Q Nt�3Y��, •:t'I 1 t�!!�+s�'rc��17 J•Y. y/lI(/' <br /> APPlioatiodiAccepted By Date" Area <br /> Grout Inspection By ' ee ID# 7 ^ <br /> Date 11SPECIAL' .elltdPeit <br /> Pump Inspecti <br /> Date <br /> ❑ WAIVERik&elve <br /> Destruction Inspect. bateIt <br /> ConstructedWAII-Depth ft <br /> COMMENTS CO r (?(� <br /> PE SC Received h ZAmount Permit/ <br /> Codes Info B Cash Rem[tted Date Service Request# ovtoice# t j.: j ,,Well ID# <br /> tf3.7 IoS 2sa•oc7 f <br /> E.� <br /> .� <br /> EHD 43-02-006 <br /> R16104 WELL PUMP PERMIIJ ,.s. <br />