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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D,o.ATMENT 304 E WEBER A-e 'FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS r,XPIRES 1 YEAR FROM DATE ISSUED <br /> 55 //10AV 99 & J ��r��� 9 a <br /> JOB ADDRESS I t Are I� CITY/ZIP a � <br /> CROSS STREET C//L�7 APN ( c/� PARCEL SIZE f Z� LAND USE APPLICATION# <br /> OWNER NAME r;J �/2 PHONE CQ rn 'y y <br /> OWNER ADDRESS CITY/STATE/ZIP 1'r'q/Yl1'669-2 <br /> -(C�� <br /> CONTRACTOR PHONE 6%—2 77? <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 LTC'-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE 7—©e/0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization (� <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number Q <br /> TYPE OF WORK Ylew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other ` <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings T\ <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method OMud Rotary ❑Air Rotary ❑Auger 1, ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth! ft Excavation in diameter ❑Open Bottom Gravel Pack/Gravel Sizein diameter <br /> ❑Conductor/-asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 4.0 in Thickness/Gauge/ASTM Sche ❑Steel ) 'Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth T00 ft ❑Neat Cement(94 1b bag/5-10 gal water) Sand Cement IcI2 1) sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name CJ ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retar nt/Accelerator(name) <br /> PEDESTAL Installed By Pbriller ❑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 I.v <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. I 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 /> nJYMU)J 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED )L TITLE �eS• DATE <br /> Si <br /> 55 <br /> l 5 �G <br /> S <br /> A J()AC URI C UIjTy <br /> N <br /> It NT <br /> 7 <br /> DEPARTMENT U E ON LY <br /> c>'' <br /> AFApplication Accepted By / t` r Date �� a Area Employee ID# J �1Q <br /> Grout Inspection By Date 102-7—��—� 13 SPECIAL Well Permit !� <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS A) F Go !3 - <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> q17 a.S°D l /200 / )Al" ' 9� <br /> 0 0 ±o oo lope")-I q 9 z <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/27/2005 <br />