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WELL/PUMP PERMIT3 9• Go �� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3tD FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS ,1 lDk, CITY/ZIP �tiCi l ��J y <br /> V <br /> Q r A <br /> CROSS STREET —7"C S APN /q 0 U O1-lc PR 'slz�E X69• ''[.AND USE APPLICATION# <br /> OWNER NAME �( f� .�4[•ra- PHONE +� <br /> OWNER ADDRESS �f"'/"'�<— CrrY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS/ CITY/STATEIZIP /p�/ <br /> SUBCONTRACTOR KLQ.;4,(�f PHONE —Y Igor—!� YS <br /> SUBCONTRACTOR ADDRESS 1-9�'5 E- ' `t/f Illi CII/TY`/STATEIZiP 5 l +C+1•�. !J ��^� <br /> LICENSE A(C-57 D C-61 D D-09 ❑Other NUMBER r 011 2-' EXPIRATION DATE /Z >I o <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE D Domestic/Private ❑Irrigation/Agricultural ❑Industrial D Water Quality Monitoring ❑Soil Sampling/Characterimtion <br /> ❑Public Water System <br /> If different from Owner: +tu yatem ame C.0n=tN­gwr e u <br /> TYPE OF WORK ❑New Well D Replacement Well ❑Well Alteration/Modification ❑Other ;n <br /> ❑Monitoring Well(s) #of wells nng(s) x°f SOf1°� Geotechnical -r lm x of boring. _ <br /> D Out-Of--Service Well D Out-0OfWell Renewal ❑Cross-Connection Repair �� <br /> D New Pum ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary D Air Rotary 9AuF ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth T 0 ft Excavation u N in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sime in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel O Q er <br /> �.,I, ,. <br /> Grout SealDepth it ❑Neat Cement(94'b bag/S-/0 gal worer) 01 Sand Cement s k miz/7 gal wattt <br /> ❑Bentonite(2U%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method D Pumped D Free Fall D Other D Retardant/Accelerator(name) L <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor D Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in O ChristyBoE D Stove Pipe <br /> PUMP ❑Submersible ❑Turbinc ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE � /( TCS S .Jnlyl DATE <br /> n� <br /> FF <br /> + 4 <br /> r <br /> O Q <br /> lar, IN <br /> DEP RTMENT U§E O LY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date �,�❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received / <br /> Constructed Well Depth /R <br /> COMMENTS <br /> PE SC Received hecldl! Amount at Permit' Invoice# Well IDN <br /> Codes Info ash Remitted rvice R uest# <br /> WELL PUMP PERMfr <br /> EHD 4342-006 <br /> 1,Vf2005 <br />