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• 'ELL / PUMP PERMIT ' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA-...•tENT 304 E WEBER AV. FL-STOCKTOND a-3 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS '.-L c /�� l CJ.fit "P5 3,.N� M U�� '� 1 t� C/l I� CITY/ZIP (aYl 1 'i C M > <br /> a <br /> �{� — <br /> CROSS STREET � {SCJ I'1 APN L�'� --'��-�(� PARCEL SIZE?()- LAND USE APPLICATION# <br /> OWNER NAME L l cc, \©QC -A PHO I�ZCJ 1 Z?>q - CA&C <br /> Z9 d � CITY/STATE/ZIP I'1�o� C_ 7 1�, � <br /> OWNER ADDRESS t W //// <br /> CONTRACTOR PHONr� ���7 9 — S�c7 <br /> CONTRACTOR ADDRESS Ps W C5. CITY/STATE/ZIP\ I <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS / 6(,,7_7 <br /> CI/TY/ST-ATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 U Other - NUMBER 6(v Z 1r3:Z EXPIRATION DATE R )o'7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE g 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/ModificationOther <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) it of orings ❑Geotechnical of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump *ump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other .tel <br /> X> <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 f` <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/S-l0 gal water) ❑Sand Cement sack mix/7 gal water i1�11 <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted (' <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑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 HO ft 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI M 24 OUR VANCE NOTICE RE UIRED FOR INSPECTIONS <br /> SIGNED "�_�71 TITLE < _�" �� �+ DATE a �~� <br /> 0AY IV I <br /> i <br /> NAR 0 21 <br /> lull <br /> A JOAQUIl <br /> _jjEAL H E R M N <br /> DEPARTMENT USE ONLY <br /> r� _ J <br /> Application Accepted By LILx�` Date -3/2 �O�' Area Employee ID# �U�S <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By ate Z ❑ WAIVER Received <br /> Constructed Well Depth `` ` ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes I Info B ash Remitted Service Request# <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/27/2005 <br />