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�•fes•-e.t <br /> --)WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D. - -ATMENT 304E WEIII- 3°°FL-STOCKTpN CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ]i, f� f jM' rs f� <br /> + l 7! 1 t �I sa -f�f� 7F - CITY/ZIP_ ✓t / I� _ <br /> CROSS STREET e'ea.-J, tl APN1)<W—( PARCEL SIZE"z'S Y� LAND USE APPLICATION# <br /> 1i� ei <br /> OWNER NAME �q[i-(�1f=_ 1"I�r,� �Q t� ,., PHONE <br /> OWNER ADDRESS t j CITY/STATE/ZIP <br /> CONTRACTOR _KLENVE LDEIZ [Vt-�. _ PHONE <br /> CONTRACTOR ADDRESS l! - t . CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP f <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE Yr ; <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irngation/Agricultural ❑Industrial ❑Water Quality Monitoring 5oil Sampling/Characterization <br /> [3Public Water System <br /> If different from Owner, Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> C3 Monitoring Well(s) #of wells ❑Soil Borin8( )s #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> 0 New Pump ❑Pump Replacement ❑Pump R air <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool C3 Push Paint 11 Other <br /> Proposed Well Depth ft Excavation <br /> t�-j/ in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size t in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft 1 <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94/b ) Sand Cement water ba 15-10 al ��' h sack mix/7 gal water <br /> 8 % ala' f <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs en File ❑Specs Submitted ; <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By . ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe '^ <br /> n <br /> LUMP 13 Submersible ❑Turbine IJ Other HP 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 <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I 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 /> I //9INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIO S <br /> SIGNED e - �� i1 TITLE _ J-� DATE ` k <br /> IJ <br /> w ,ti oo � i/ <br /> 00— <br /> + i -r + <br /> tl (oft ms-neo-p) <br /> � � .moi � � R.,..w■ ; <br /> f�Ej DL <br /> N <br /> ....+s i 1■1 S M u# <br /> r <br /> J DEPARTMENT USE ONLY <br /> Application Accepted By Date C5` <br /> I �A Area Employee ID# <br /> Grout Inspection BY .1- / d i1Gr, j Date "j `— } <br /> r� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 0 WAIVER Received ' <br /> I <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received (Check#! Amount Permit/ <br /> Codes Info B ffw Remitted Date Invoice# Well ID# <br /> Service R uest# <br /> 437,L iso 6-L+ 1' :2 <br /> EHD 4302.1106 _ <br /> 1/2212005 WELL PUMP PERMIT <br />