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WELL / PUMP PERMIT 401 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIwRTMENT 304 E WEBER.,v— 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 p� '�J ASQL4.f h ��•��,`-�� W r �TY/ZIP r k-1111-e"Cet <br /> CROSS STREET &&4,-Ct-, APN — PARCEL SIZE L /�, yhll LAND USE APPLICATION# <br /> OWNER NAME PHONE <br /> OWNER ADDRESS �- <br /> 14 CITY/STATE/ZIP GL2t� Z L/� �-'cG <br /> 0 _ �z <br /> CONTRACTOR. _ 1 n I _I n„��` �_C PHONE —ell <br /> CONTRACTOR ADDRESS —7W"E— �' �^ 1 /�_ CITY/STATE/ZIP <br /> SUBCONTRACTOR 6 PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER / EXPIRATION DATE C// 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring 01Soil Sampling/Characterization <br /> ❑Public 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 d <br /> # <br /> ❑Monitoring Well(s) #of wells ❑Soil BoringM of bonngs s) Geotechnical of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection epair K J <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary <br /> ❑Air Rotary .Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth V ft Excavation to diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameteuctor 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/b bag/5-10 gut water) ❑Sand Cemen sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name � '1 f ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Velerator(name <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑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 /> MI UM 24 HOUR ADVANCE NOTICE REQUIRFOR SP C�S <br /> SIGNED TITLE <br /> n <br /> AlUr <br /> a <br /> a <br /> 9 4LL <br /> O <br /> g o <br /> 1 <br /> � r <br /> r <br /> sA4 JAUi oN <br /> - r ; R:rr �- t-sem e <br /> c <br /> Application Accepted By Date l Area Employee ID# `73 7 l7 13/� <br /> Grout Inspection E Date !/ ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS / <br /> PE SC Received Check#/ Amount DatePermit/ Invoice# WellID# <br /> Codes Info By Cash Remitted Service Re uest# <br /> 3 <br /> WELL PUMP PERMIT <br /> EHD 43-02-006 <br /> 1/27/2005 <br />