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1 <br /> { WELL/PUMP PERMIT 0 <br /> SAN JOAQUIy COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3Y°FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7097 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS a71 • <br /> S. //GLfT/s� O�� CITY/LIP I 1 I w� `I r C' y <br /> CROSS STREET �L Q APN.ZZ�s L' �ARCEL S17.E3 LAND USE APPLICATION# <br /> OWNER NAME t'7a' I Cf �NZc 1/I/��^S uv-s y / PHON E� � <br /> OWNERADDRESS �C -'>y�� LL-1`/-1 ri ��• CITY/STATFJZTTIP FI_ d'�X --E[1. p�S36.G' <br /> CONTRACTOR I�/I �t'(,�(P HONES,[-4 <br /> P 2 <br /> [ <br /> CONTRACTOR ADDRESS I /�P✓-S rte-(r- CITY/STATE/ZIP / j,^ PS <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/ <br /> S <br /> TATE/ZIP /5 <br /> LICENSE XC-5757 ❑C-61 ❑D-09 ❑Other NUMBER AIC- ; EXPIRATION DATE 2-1 ./-7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Sectlon <br /> INTENDED USE ❑Domestic/Private Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ' ❑Soil Sampling!Characterization <br /> ❑Public Water System <br /> Ifdifferent from Own- mtr System eme Contact amo or Phone Number <br /> TYPE OF WORK(wJew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) x of bonngs ❑Geotechnical a ofbo" <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair (� <br /> ❑New Pump ❑Plump Replacement ❑Pump Repair 1 <br /> WELL CONSTRUCTION <br /> Drilling Method P*ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth,27 7 ft Excavation_/<" in diameter ❑Open Bottom )KGravel Pack/Gravel Size in diameter <br /> ❑Conducto astng in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel (Mastic ❑Stainless Steel ❑Other <br /> r . <br /> Croat Seal Depth_�ft ❑Neat Cement(94/b bug/S-!0 ga/wafer) ❑Sand Cement sack mu/7 gal water <br /> OZ.�Bcntonite(20°/solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method CA-lpmped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller mp Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length It Thick in ❑Christy Bos ❑Stove Pipe v <br /> PUMP ❑Submersible ❑Turbine ❑Other UP Pump Set ft Standing Water Level it <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 /> 1MINI M L 24 HOER ADVANCE NOTICE RE91-1 IIRnED FOR INSPECTIONS <br /> SIGNED �)L*C- `411p C;dd TITLE �Y�1 l IX✓� DATE <br /> v <br /> E r <br /> V00 I <br /> Z <br /> cZ <br /> E <br /> / v <br /> E rRTMENT (USO 'LY <br /> Application Accepted By \ atc a AreaEmployee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit / <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth A <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well IDN <br /> Codes Info as Remitted Servi 5E Eeguest# <br /> EHD IJ-02-006 <br /> WELL PUMP PERMIT <br /> 1/272005 <br />