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D() <br /> /ELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP—.- AENT 304 E WEBER AV, °FL-STOCKTON CA 95202 - (209)468-342 <br /> NON-REFUNDABLE PERMITCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 7- <br /> JOB ADDRESS ^ n ]_h\y �l ` s� SS <br /> CITY/ZIP J � I� <br /> CROSS STREET 1 SCJ APN '1��O �7` t PARCEL SIZE _LAND USE APPLICATION# F <br /> OWNER NAME CcAe,\i �Z 5 L4 C—,(,, Zq i I n <br /> OWNER ADDRESS �.`J• �7LC, ��'1w I `, CITY/STATE/ZIP�J tonoU 1 ✓G <br /> CONTRACTOR G � 1 C�I c 1 I( 1 PHONE z Gl " ' _ Ll 0 <br /> rr-- _ c 531 <br /> CONTRACTOR ADDRESS �nO V CITY/STATE/ZIP 7 C ` <br /> SUBCONTRACTOR V V`+` 1, ``� J \�C• PH�I(7 3 ' G ��J-ll ?C)L <br /> SUBCONTRACTOR ADDRESS`l �0 as 1,vf:��S air-� (01rt J1 V 14 V CITY/STATE/ZIP - � [,t L <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER &boan EXPIRATION DATE <br /> 3\OCT O <br /> � aG`GEOGRAPHICAL INFORMATION: Coordinates X3K~"V �-Dv' Y\Z\ �+ t+ <br /> 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 <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings �Geotechnical �4 of borings <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 ❑Mud Rotary ❑Air Rotary )Lger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth 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 ❑Stainless Steel ❑Other <br /> Grout Seal Depth_�>� ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> f�Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement et'hod ❑Pumped ❑Free Fall ❑Other `, C3 Retardant/Accelerator(name) v! <br /> PEDESTAIL <br /> Italled By ❑Driller ❑Pump Contractor ❑ Other ',IJ <br /> ❑ onerete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP mersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERT FY 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. 1 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 NI U4 HOUR ADVANCE NOTIC REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> \ V <br /> N O N Y <br /> E VI OI M " <br /> 1E <br /> dD PA TMENT U E NLApplication Accepted Date Area Employee ID#!����7�-�� 9 <br /> �Gra�i Ffdspection By '"+ Date '' ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth 7 ft <br /> COMMENTS P4 0; 0d�L 0 �bC/�/i�F 1>/� .���f GL�G�i�I CJ G�-47Z-}G <br /> PE SC Received <br /> Chec Amount Permit/ <br /> Codes Info B Cash emitted Date Service Request# Invoice# Well ID# <br /> S° to <br /> 590b-5-0 2S-7 <br /> EHD 43-02-006 ��'I� �'�G� �L' �`5 � WELL PUMP PERMIT <br /> 1/27/2005 <br />