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;���`°`,''��' • . e �nru.�t;� •Drs�.St�.--�'a�- � D�`,, �/� � y�i� <br /> LL / PUMP PERMIT 3 <br /> •SAN'.:�',QUIN COUNTY ENVIRONMENTAL HEALTH DEFRRTMENT 304 E WEBERd*L-STOCKTON CA�9951i2 �¢p <br /> 'NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEARWU IMSSUEED <br /> JOB ADDRESS ROADCITY/ZIP M <br /> CROSS STREET 5" d'-tog H 90A-aPN ZO/0(/ 00'3 <br /> yPPARCEL SIZE� /7 LAND USE A <br /> PPLICATION# <br /> OWNER NAME ri-94Wk" /^ COAPOA ep PHONE <br /> OWNER ADDRESS F,0- /'O'X' < 77 9 CITY/STATE/ZIP TwDe-N o —/-x761ZI <br /> CONTRACTOR //&y/ & �c�( ,6A) <br /> PHONE C?OC/' + Vim/—';rM <br /> CONTRACTOR ADDRESS 1300 LIAU % VA t Aq- Vd CITY/STATE/ZIP r\M 100M- <br /> — 1SUBCONTRACTOR 5PHONE <br /> SUBCONTRACTOR ADDRESS PRIVE CITY/STATE/ZIP /�6�',/0tyt2 [ —f Com!jQ176:0 <br /> LICENSE QYC-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y 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 CAP /40f47V 4AJq 4% <br /> Monitoring Well(s)_ #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #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 ❑Auger ❑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 /> ❑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 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> /MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE C//�Y/J �� ��J�` DATEPA <br /> h- <br /> I 1611f nn; <br /> i <br /> AQuIr <br /> J C1.XjIRTi <br /> L E <br /> n DEP RTMENT USE ONLY <br /> Application Accepted By l' Date Z J Area Employee ID#! [ <br /> Grout Inspection By f1 Date—\ �1 i 1 e'L '2 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received h AmountgDate Permit/ Invoice# Well ID# <br /> Codes Info B Cash RemittedService Request <br /> # <br /> S S d-* F�CrU � 0 <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/27/2005 <br />