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U7V T I I PUM � a c� <br />P PERMIT C- os-�s , <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ,.. PARTMENT 304 E WEBS,... VE 3"" FL- STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL, 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS /saT E '�-ahs'%f - CITY/ZIP CQ S .E22-0 <br />CROSS STREET[, yI{ qpN _ r/v- �� PARCEL SIZE -79W ,AND USE APPLICATIO <br />OWNE NAME ZaWt ® T{.yrhj tt: e_ O <br />�- PHONE 1 <br />OWNER ADDRESS �LL�.sTa�l ,f - CITY/STATEIZIP q,j 29-0 <br />CONTRACTOR Mail / IPA PHONE ��7Q <br />CONTRACTOR ADDRESS V 'X1 CITY/STATE/ZIP "I C O S,�j O <br />3UBCOIITRACTOR _ PHONE <br />Well <br />Casing <br />ut Seal <br />Grout <br />ADDRESS <br />❑ C-61 ❑ D-09 ❑ Other <br />NUMBER <br />CITY/STATE/ZIP <br />EXPIRATION DATE in — V tU <br />INFORMATION: Coordinates X Y Township _ <br />❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring <br />❑ Public Water System <br />If different from Owner: Water ystem NaMe <br />Range Section <br />Sampling/Characterization <br />ontact Name or one Number <br />❑ New Well ❑ Replacement Well 0 Well Alteration/Modification 13 Other <br />El Monitoring Wel!(s) # of wells ❑ Soil Bortng(s)a afborings rf of borings <br />l2iiGeotechnical T�� <br />❑ Out -Of --Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair 1G <br />❑ Mud Rotary ❑ Air Rotary OVAuger ❑ Cable Tool ❑ Push Point <br />Depth s - !jQ ft Excavation �`in diameter ❑ Open Bottom <br />❑ Conductor Casing in diameter / Conductor Casing Depth <br />❑ Other <br />❑ Gravel Pack / Gravel Size in diameter <br />ft <br />Diameter in Thickness/Gauge/ASTM Sched <br />11 Steel ❑Plastic ❑Stainless Steel ❑Other <br />Depth ft ❑ Neat Cement (94 1h hag / 5-10 gal waier) ❑ Sand Cemeat sack mix 17 gal water <br />❑ Bentonite (2(r% solids) ❑ Manufacturer Spec % solids % Name irT .Specs on File ❑Specs Submitted <br />Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / ccoler for ame) <br />Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Lengt <br />❑ Submersible ❑ Turbine ❑ Other HP <br />ft Thick in ❑ Christy Box ❑ Stove Pipe <br />'t ft Standing Water Level ft <br />CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />COMPENSATION LAWS. <br />SIGNED <br />M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />TITLE ijll" LLyI .��ytQ� DATE 7 <br />DieP,(R <br />Application Accepted By <br />Grout Inspection By v - <br />Pump Inspection By <br />Constructed Well Depth <br />COMMENTS <br />-- <br />PE SC Received `Cheel <br />Codes Info B Cas <br />EHD 43.02.006 - <br />M 2005 i, <br />M <br />a <br />d <br />a <br />ly <br />MENT USE/ONLY 7/ <br />-'� �.� Area EmployeelD#, a(0� <br />Date❑ SPECIAL Well Permit �� <br />i} <br />Date ❑ WAIVER Received <br />Date CUwlllly L Invoice# Well ID# <br />Service Request # <br />WELL PUMP PERMIT <br />