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ELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAk t HENT 304 E WEBER AVE FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERWT, CALL 209 953-7697 FOR I NSPEfijTI0N.S EXPIRES t YEAR FROM DATE ISSUED <br /> I CITY/ZIP a <br /> JOB ADDRESS <br /> —7 L��t 0 <br /> tv <br /> CROSS STREET1� �� APN �� / C%' L('PARCEL SIZE LAND USE APPLI AT[ON# / � tpy <br /> OWNER NAME .!ZF� L1/ 'Cr'`/✓�� PHONE <br /> OWNER ADDRESS A rt.-f CITYISTATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> S <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDFP USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name ontact Name or one Number l <br /> TYPE OF WORK ❑New Well ❑Replacement Well 11 Alteration/Modification ❑Other ^+i <br /> #of borings ❑Geolechnicak #of borings <br /> El Monitoring Well(s)_H ofwells ❑Soil Boring(s) <br /> ❑Out-Of-Scrvicc Well ❑Ow-Ol'Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Too] ❑Push Point D Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / 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 1h hag 15-10 gat water) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) Q Manufacturer Spec%solids % Name ❑Specs on File 0 Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fail ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL JnValled By ❑Driller ❑Pump Contractor Other_4l -c-::22 <br /> ncrete Pedestal Dimensions:Width ft Length '-2— ft Thick — in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine d Other HP Pump Set ft Standing Water Level ft <br /> 1 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. 1 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 /> ��'""" 'MINIMUM 24 FLOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS f <br /> SIGNED ✓ /.fvtA t � y�T"1 TITLE �.' �_(-t? j•lam:�., DATE �!'' i ��} `..J <br /> r' <br /> r O _ <br /> otv <br /> ER1 �1 <br /> D ARTN1E NT U-.,11' E O t Y <br /> Application Accepted By Date _� Area / Employee 1D# <br /> GroutInspection By' Date ❑ SPECIAL Well Permit <br /> Pump Inspecon By --�-1 �� Date 'r ❑ WAIVER Received <br /> Constructed Well Depth l <br /> U. <br /> I COMMENTS <br /> PE SC Received ec Amount Permit/ � <br /> nvoice# II ID# <br /> Codes Info B esh Remitted ate Service Request# <br /> J <br /> EHD43-02-006 WELL PUMPPERMET <br /> 1127/2005 <br />