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WELL / PUMP PERMIT <br /> SUN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°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 V CITY/ZIP y <br /> ! V1 APN�C) °V o <br /> CROSS STREET 4 PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME 1Y��1 '�'✓ v�o PHONE 7, _ <br /> OWNER ADDRESS �! iM l�� CITY/STATE/ZIP <br /> CONTRACTOR Xi—A ojP-0-- Intl /bq /'PH/ONE I <br /> CONTRACTOR ADDRESS I�\1 CITY/STATE/ZIP (N��'J <br /> " '�� �'���G ` <br /> SUBCONTRACTOR •i < PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> '2 Fn C O <br /> LICENSE —K-57 ❑C-61 ❑D-09 ❑Other NUMBER �J"J EXPIRATION DATE 6 M ®0 <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 P one Num er <br /> TYPE OF WORKlew Well replacement Well ❑Well Alteration/Modification ❑Other , <br /> #of borings ❑Geotechnical #of borings <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) <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.;*!Wud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ' 0 ft Excavation in diameter ❑Open Bottom AGravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched'7'O ❑Steel APlastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) and 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 % riller ❑Pump Contractor _ ❑ Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ubmersible ❑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 /> INIMUM 24 HOUR ADVANCE NOTICE gREQUIRED FOR INSPECTIONS <br /> SIGNED TITLE W N�+� DATE V �J <br /> 03 ! <br /> ! - <br /> S ' <br /> SAKI <br /> v <br /> ZTLT D PA <br /> jU de <br /> .. <br /> Of <br /> A. <br /> VC <br /> Or <br /> 11 O'A <br /> DEP RTMENT_USE ONLY --77 <br /> Application Accepted By <br /> ` Date Area Employee ID# 7T �` <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date / /06 ❑ WAIVER Received <br /> Constructed Well Depth It <br /> COMMENTS ti5Z� 6-20Qi0' 546t-- IT- �C� Z 1-5A- <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Re uest# <br /> 4° 5Lr-YN n, 37 <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/27/2005 <br />