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r I <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE Y°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 /Zip r+cy (J/✓a/: CITY/ZIP rSp <br /> a <br /> DQ d` e <br /> CROSS STREET Irl'14.c Ma APN ARCEL SIZE LAND USE APPLICATION# <br /> �r I <br /> OWNER NAME r /-S. �'[R-IPf IZCI 7-If PHONE <br /> �7 P _ <br /> OWNERADDRESS LC 770 S g p_ CITV/STATF/ZIP �a�.� C//1 p 9S 37�_ <br /> NO <br /> CONTRACTOR W � �.B o11� S•9� �- L��CL�c 104de.�J1�, �1L 1�/'.t PHONE(1',-7/ O.�S"LcF/cy <br /> CONTRACTORADDRESS r �• ' upX JSy CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS py[ 'l CITY/STATE/ZIP <br /> iLICENSE ❑C-57 '❑C-61 O D-09 & P Ll,her G/O NUMBER 7399 ? EXPIRATION DATE / Q <br /> I GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE Domestic/Private O Irrigation/Agricultutal ❑Industrial O Water Quality Monitoring O Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from A.-rrcr. arer ysam ame .—,Nemo or one N—b., <br /> TYPE OF WORK ❑New Well O Replacement Well ❑Well Alteration/Modification O Other <br /> O Monitoring Well(s) #of wells ❑Soil Boring(s) a°fbonngs ❑Geotechnical a of borings <br /> ❑Out-Of-Service Well O Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> O 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 O Open Bottom O 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 th bag/5-10 gal warm) O Sand Cement .sack mix/7 gal water <br /> O Bentonite(200/solids) ❑Manufacturer Spec%solids__% Name O Specs on File O Specs Submitted <br /> Grout Placement Method ❑Pumped O Free Fall O Other O Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller O Pump Contractor ❑ Other <br /> O Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMPP4ibmersible ❑Turbine ❑Other HP 2 Pump Set 30 It Standing Water Level <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. 1 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 ADVANCE NOTICE EQUIRED FOR/INSPECTIONS ` <br /> ~ SIGNED TITLE t1.P') TC��n.c•.� DATE 6� /C✓ <br /> f <br /> IN I <br /> CA Ill <br /> D <br /> p Ul <br /> E <br /> --D -P R T M E N TSU�E N <br /> ApplicationAccepted Ba, 1 Date Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 4 Z Z ❑ WAIVER Received <br /> Constructed Wel/lJdepth It <br /> COMMENTS - <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted �1Service Request# <br /> o Q <br /> EHD 03-07-006 WELL PUMP PERMIT <br /> 1.12712005 - - <br />