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�o <br /> WELD/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 -(209)460-3420 <br /> NOON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> _ 0 J <br /> JOB ADDRESS n/•�• 47F H—)•12. f- �, /.slpJl fGN /Y.� CITY/ZIP �00r �7 Z�� m <br /> CROSS STREET IL,CNN rS®f/ RDAPNQdoI)ab S.j --PrtRCELSIZELAND USE APPLICATION# �1 R <br /> ' OWNER NAME S' QEE4-: A 0—Pn EC7 L' _ PHONE 4 je— t�I c// / <br /> OWNER ADDRESS S/ CITY/STATE/ZIP <br /> CONTRACTOR /,IFI L- 9, A,,)orea4ey J A550G.{ rAj— PHONE ?,/y')-37,P <br /> ' CONTRACTOR ADDRESS �/�2- IIJ fr W}j�Z;i}L C-'A CITY/STATE/ZIP G.O®r _/ �-24 a <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS' CITY/STATE/ZIP /' V LICENSE �fC-57 ❑C-61 ❑D-09 ❑Other NUMBER114 EXPIRATION DATE [� ^O �• <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural Cl Industrial ❑Water Quality Monitoring Soil Sampling/Characterization 777--- <br /> 0 Public Water System <br /> ' IfdiOerent from 0— Water SyStern Name -Mr t eme or one N.Mbel <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ofhorings <br /> ElMonitoring Well(s)_#of wells 0 Soil Boring(s) 2L�" gofborings ❑Geotechnical ptil <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair " <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WEa.l CONSTRurTION <br /> Drilling Method O Mud Rotary 0 Air Rotary Auger 0 Cable Tool ❑Push Poim ❑Other <br /> Proposed Well Depth 10-4-0 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 Cl Stainless Steel ❑Other <br /> Grout Seal Depth r&4/I It ❑Neat Cement(94 Ib bag 15-10 gal wafer).,,;r �elgPpy y f/O—✓ r'10/L"Ssack mix l7 gal water <br /> O Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method 13 Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name)'e" pa; NraL'G4 <br /> ' PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> u P ❑Submersible ❑Turbine ❑Other HP Pump Set it 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 /> 1 1/]�OMUM 24 II®U3 ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED "-`� f� I ITLE '/1- NATE 4 •7 �� <br /> r <br /> •` •,�_' <br /> J <br /> \� <br /> 3 7 <br /> N J0,kat <br /> II Or MEN L o <br /> 1 + X <br /> -Tr---TF li <br /> ff <br /> /-r/. . -::: U <br /> - - L Aq <br /> y <br /> Application Accepted By 11� Area Employee ID# � 7 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> GnnstsD�tsd3ValyWpth / <br /> COMMENTS /a2 i �/ / I �r ti �'rF�i ii =Z <br /> ' PE SC Received Check#/ Amount Date Perinitl <br /> Invoiced Well 1D# <br /> Codes Info By ash Remitted Service Request# <br /> ' EHD 43.02.006 WELL PUMP PERMIT <br /> 1/27/2005 <br />