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t <br /> J (-)WELL / PUMP PERMIT. <br /> R <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DLrARTMENT 304 E WEBE3"°FL-STOCKTON CA 95202 ry= ( 0 L3_420 <br /> NO PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES ] YEAR FROM DATE ISSUED <br /> 1 J08 ADDRESS - G2 C ��S` t „S C IP..!—,_ CITYIZIP_ <br /> { CROSS STREET1 i� <br /> APN �,�PARCEL SIZE -C t� LAND USE APPLIC N# v <br /> f 7c <br /> OWNER NAME L Q mn <br /> T� +� <br /> PHONE <br /> �s <br /> OWNER ADDRESS CITY/STATE/ZIP_IJ / <br /> CONTRACTOR <br /> 7 {/ L PHONE > <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP / <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE 7 ❑C-61 ❑D-09 ❑Other NUMBER <br /> (1 EXPIRATION DATE ��r.` / <br /> GEOGRAPHICAL INFORMATION: Coordinates X <br /> V Township Range Section <br /> INTENDED SE XDomestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: eter ystem ame <br /> ontact ame ar P one um er <br /> TYPE OF WORK ❑New Well Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of welts O Soil Boring(s) #afborings #of borings <br /> ❑Geotechnical <br /> ❑Out-Of-Service Well ❑Out-Of-Service We]I Renewal <br /> (3 Cross-Connection Repair <br /> ❑New Pum ❑Pump R iaccment ❑Pump Repair <br /> rProposed <br /> TRUCTION <br /> hod Mud Rotary ❑Air Rotary ❑Auger ❑Cable Too] ❑Push Point ❑Other <br /> Well Depth� ft Excavationin diameter ❑Open Bottom Gravel Pack 1 Gravel Size <br /> ❑Conductor Casing in diameter / Conductor Casing Depth Itin diameter <br /> easing Diameter In Thickness/Gauge/ASTM Sched <br /> ❑Steel plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941b bag/S-IO gal wafer) ❑Sand Cement - <br /> N&iBentonite(2Q%solids) ❑Manufacturer Spec%solids % Name sack mix!7 gal water y <br /> [7 Specs on File ❑Specs Submitted <br /> Grout Placement Method meed ❑Free Fall 11 Other 13 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP . ❑Submersible ❑Turbine ❑Other Hp <br /> 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 t_ <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS "1 r <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> f. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> tfF <br /> SIGNED L TITLE P <br /> DATE <br /> i� <br /> or <br /> i <br /> d V _ <br /> I� <br /> r <br /> f <br /> > <br /> 't <br /> r <br /> n <br /> DEPARTMENT USE ONLY <br /> Application Accepted By DateO f / <br /> Area Employee ID# <br /> Grout Inspection By Date 13 SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth It i <br /> COMMENTS A115W 1-C-T OF ._C 0 .2 tLcc t 5 j <br /> r n.i�,l: h+v7'i �r G_ i C• . L`� S�t,t:..0 d •� L k (j' 't Cw t .�E/�C li�.t/ <br /> PE 5C Received Cheek#1 Amount Permit) <br /> Codes Info B Cash Remitted Date Invoice# Well ID# <br /> Service Request# <br /> 3. 7t� rev `d <br /> EHD 43.02.006 <br /> 1l27/2D05 WELL PUMP PERMIT <br />