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kejfi/I -Ed ELL / PUMP PERMIT �r occ 5 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAWMENT . - ' 304 E WEBER AIS FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS w CITY/ZIP q C <br /> y� 0��� � <br /> CROSS STREET �JC�jT�/ /���!✓yy�� APN Q 9-0� Q PARCEL SIZE LAND USE APPLICATION# <br /> �✓�KiTCti�.+' 11VO p��/YPMOVren PHONE y <br /> OWNER NAME <br /> OWNER ADDRESS Q(/ v v �,�/��'T`� /��(/� CITY/STATE/ZIP 7� <br /> CONTRACTOR 9rye / Af� ���"`"•/// /rs""�-� � CB+$) p�PHONE �yl� s�a� _7M / � <br /> CONTRACTOR ADDRESS Q�p(�✓0 (�/��Za ✓"Zf rA b IVV E CITY/STATE/ZIP (J�/1/`�(ygN�l�l J�/�1�� 64 011`2(0 5 � <br /> SUBCONTRACTOR Rl IJ `(.`/`vJ//kyc '`ol/.(/dL— PHONE <br /> `(� L —ff6'0 7 77 //t <br /> SUBCONTRACTOR ADDRESS !(f' 1 G G �`J!�7 f� l /C�,ITY/STATE/ZCI�P �Y,`'1 �, J"' 7�'1 <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 0533 0 EXPIRATION DATE / h -zoo^-7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section Cj <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 P oneum er <br /> TYPE OF WORK �kew Well ❑Replacement Well 13 Well Alteration/Modification her !!Ory <br /> ❑Monitoring Wells) #of wells ❑Soil Boring #of borings s) ❑ #of borings <br /> Geotechnical V-) <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> [3 New Pump ❑Pump Replacement ❑Pump Repair `>A- ` � <br /> WELL CONSTRUCTION ��'� 4Dkt/1'/v(S-1S <br /> Drilling Method ❑Mud Rotary )!,(Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth 20 '5 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 'astic ❑Stainless Steel 13 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MUM 2 2UR ADVANCE NOTICE REEQ"UIREDr lFOR INSPECTIONS <br /> SIGNED A TITLE DATE / S <br /> N <br /> JO 1.1 A <br /> �p R <br /> DEPARTMENT SE ONLY <br /> � O D�� <br /> Application Accepted By �a�-�^--�/ Date � <br /> D _ Area Employee ID# <br /> Grout Inspection By g: �4ss Date -7 —/ __�S' 13SPECIAL Well Permit <br /> Pump Inspection By Date 13WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Cec Amount D e Permit/ Invoice# Well ID# <br /> Codes Into BY Cash Remitted Service Request# <br /> WIT <br /> "o <br /> EHD 43-02-006 � <br /> WELL PUMP PERMIT <br /> 1/27/2005 �t© <br />