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WELL / PUMP PERMIT m? m 6 <br />SA.N JO ..,,-AL HEALTH DEPARTMENT 304 E WESER AVP 3- FL- STOCKTON CA 95202 - (209) 46&3420 <br />N019-L� F <br />RMIT CALL (2(19) 953-7697 FOR iNSPECT(ONS EXPIRES I YEAR FROM DATE ISSUED <br />JOB ADDRESS ` �� 1 J+ k CtTY/ZIP_ YL <br />CRQss STREET ! APN .+s / L' Q �AltcEL SIZE 3 ( 3,3 LAND Us 'i, TION #_ <br />OWNER NAM\- 4,- _ _ _ PHONE -' <br />OWNER ADDRF.Si C7111STATE/ZI1 <br />CONTRACTOR _1 //LT/ / /'i!{�f � _. PDONE•'1S^�J� <br />CONTRACEOR ADDRf.4, L CrrY/STATVZIP_Zy4n �u 4-jL P <br />r <br />SURCONTRACTOlt _ L_ _..�.�� PHONE <br />SUBCONTRACTOR ADDRMS CFFVSTATE/ZIP _` __ 4� <br />LICENSE: --57 ❑C-61 0-09 0Other NL'MBI, _ 2 - EXPIRATION DATE���.L _ <br />GEOGRAFHICAL I.YFORMATION.- Coordinales X Y Township_ Rrnge Section_ <br />NTENDEn USE mcstic(Private Q Irrigation/Agricultural Cl Industrial 0 Water Quality Monitoring CJ Soil Sampling/Characterirxtion <br />0 Public Water System <br />If 110-1 r.. n•*: <br />rYPE OF WORK erNew Well ❑ Rcplecernent Wcii 0 Well Altcrauon/Modification ❑ Other <br />0 Monitoring Well(s)- # of wells 0 Soil Borings) _ —.P 0 Ccoteehnieal _,—" <br />IJ Out -Of --Service Well OOut-Of-Scrvice Well Renewal 13 Cross-Connoction Repair <br />❑ New Pump ❑ PUIIPRepiacemcnt 0 Pump Repair <br />Dlilthrg Method O*ud Rotary 13 Air Rotary 0 Auger 0 (:able Tool 0 Push Pemt 0 Other <br />Proposed Well Depth -"a.SV __ it Excavation _ ZG-_- _in diameter ❑ Open Bottom ravel Pack / Gravel Size _in disinicter <br />❑ Conductor Casing in dianicter Conductor Casing Depth <br />W'eli Casing Diameter tj6P in 1hickncss'Gaugc1ASTtvT Schcd _X500 ❑ Steel Mastic 0 Stainless Steel 0 Other <br />Grout Seal Depth 1pD ft ❑ Neat Cement (94 !b bag /5-10 got tourer) D Sand Cement— _ 4 _sock ma / 7 gal water <br />R_tcntonitse�(209: solids) 0 Manufacturer Spec % solids % Name _ 0 Specs on File d Specs Submitted <br />Grout Placamenl Method pigumned ❑ Free Fail 0 Other O RctaAant / Accelerator (name) <br />PEDESTAL Installed By 0 Unller ump Contractor ❑ Other _ <br />❑ Concrete Pedestal Dlmenslom: Width 9 Length _ 11 Thick to 0 Christy Box ❑ Stove Pipe <br />puss 0 Submersible D Turbine ❑ Other HP Pump Sct ft Standing Water Level fl <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. 1 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 LAW'S. <br />� <br />ME, MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED 1/1 L✓ z�'I ITLE L P ('1140DATE d A "2:2- <br />�D <br />S;J <br />Ln <br />IR <br />U <br />DEPARTMENT USE ONLY <br />Application Accepted By � `��'. _ Dote L_ n Area _. _. � ._ F-mployee ID# 4-014 S c <br />Grout Inspectio", By _ [Vete _ y( __. ❑ SPECIAL Well Pe IIL(t <br />Pump Inspection By Date 11 ❑ WAIVER Received <br />Constructed Well Depth R <br />�F�Gc;4�� _ <br />PE SC Receivedchcekk/ <br />Codec Info B <br />�j Arnou Permlt/ <br />Cash ken-Alted Date Service Request M Invoice 8 well [Di <br />-2 <br />END 43.42-006 WELL PUMP PFAMIT <br />1:272005 <br />