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WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHARTMENT 304 E WEBL.--.-VE 346 FL-STOCKTON CA 95202 - (209)468-3420 ;I <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS <br /> EXPIRES l YEAR FROM DATE ISSUED <br /> �' _ _ CITY/ZIP G <br /> JOB ADDRESS ��--- I j� ) _ d � <br /> APN <br /> 6 PARCEL SIZE° ` LAND US LI N X <br /> CROSS STREET <br /> PH <br /> OWNER NAME <br /> CiTYISTATEIZIP <br /> OWNER ADDRESS <br /> r� ° \ PHONES iSS 3 2 T <br /> CONTRACTOR 1 <br /> / CITYISTATEIZiP 62 . <br /> CONTRACTOR ADDRESS (,/ , � aallI � 910 <br /> PHONE <br /> SUBCONTRACTOR <br /> CITY/STATE/ZIP <br /> SUBCONTRACTOR ADDRESS <br /> LICENSE ❑C-57 �C-61 ❑D-09 C1 Other NUMBER L5 EXPIRATION DATE <br /> Y Township Range Section <br /> GEOGRAPHICAL INFORMATION: Coordinates X <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial Cl Water Quality Monitoring ❑Soil SamplinglCharacterization <br /> ❑Public Water System ater stem eme ontact eme or one um er <br /> if different from Owner: y <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well AlterationlModifiication #of 13 Other #of borings <br /> Cl Monitoring Wel](s) <br /> #of wells ❑Soil Boring(s) ❑Geotechnical i <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> O—New Pump ❑Pump R lacement ❑Pump Repair ~ <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool 13 Push Point 13 Other f� <br /> Proposed Well Depth <br /> ft Excavation in diameter ❑Open Bottom ❑Gravel Pack I Gravel Size in diameter <br /> ft J <br /> ❑Conductor Casing in diameter 1 Conductor Casing Depth <br /> [I Stainless Steel ❑Other C <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schell ❑Steel ❑Plastic sack mix!7 al water V' <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement g <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) <br /> n. <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 /> PUMP Submersible ❑Turbine 13Other HP J Pump Set f #� ft Standing Water Level c�5 ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> D RULES AND REGULATIONS. I ALSO ICENSE IS <br /> OA�NT AN D ACTIVE DIVANCES, STATE LAWS, AN THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE IFY THAT MY REQUIRED LWITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ,0 6 <br /> I ~` <br /> TITLE�ld�l��t J C-rl4R DATE <br /> SIGNED l <br /> GU <br /> N <br /> i <br /> DEPARTMA& SE ONLY <br /> - j �� Area Employee ID# <br /> Application Accepted$y Date // <br /> i <br /> Grout Inspection By . " Date [3 SPECIAL Well Permit <br /> t pumpinspectionInspection By tP 'f Date /—.. ❑ WAIVER Received <br /> � <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received eireck#f Amount Date Permit/ Invoice# Well ID# <br /> Codes into B as Remitted Service R nest# <br /> WELL PUMP PERMIT <br /> EHD 43-02.006 ' <br /> 1/27/2005 <br /> 4 <br />