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WELL 1 PUMP PERMIT ' <br /> i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3A0 FL-STOCKTON CA 95202 - (209)465-3420 <br /> NON-REFUNDABLE LE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS ` ` +5 T!ewe— AwgS CITY/ZIP <br /> p O <br /> CROSS STREET <br /> APN 1 1 J [ 1 PARCEL SIZE r ) LAND USE APPLICATION <br /> 'J� �ut—HSE y <br /> �vPHONE y <br />� OWNER NAME [� c <br /> OWNER ADDRESS I� - -I CITY/STATEIZIP <br /> CONTRACTORk4NA��Mg— KVt" sSoG Iik'C�i PHONE <br /> CONTRACTOR ADDRESS <br /> f `7�1U 'l rK`• rOER` '41 CITYISTATEIZIP <br /> / <br /> SUBCONTRACTOR `+ xs W ���4� PHONE <br /> SUBCONTRACTOR ADDRESS_ 1� CITY/STATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 2O� EXPIRATION DATE� aIp 6 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural 11 Industrial ❑43t ual i z1g ii n t tion <br /> ❑Public Water System <br /> If different from Owner: Water System Name octan N me or N r + 1- <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ay ave expll Wj L ouOr <br /> gs <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) s being o tetodlnr of <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal Q -Re <br /> ❑New Pum ❑Pum Replacement ❑Pum Repair <br /> � "��"'N Health Division <br /> I WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary Cl Air Rotary XAuger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth SO ft Excavation� in diameter E3 Open Bottom ❑Gravel Pack 1 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 150 ft Neat Cement(94/h bag/5-10 gat water) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File 0 Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall 1RJ 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI MUM 24 HOUR ADVANCE NOTICE REQUIRED <br /> FOR INSPECTIONS <br /> SIGNED TITLE � .DATE <br /> 1 <br /> I <br /> \POR SOLMY OF WAHEHPUSE5 <br /> \ -_145-19 <br /> -_off: <br /> z. <br /> ". _...r. r ® IRON- i+fT <br /> - _ -- <br /> l�L MAL V1 <br /> ..^.r. ..� n •vrE r....r n,ex s...N.,,tn..,,.nrv, m.sv..mp iaSFy r9 k <br /> Y <br /> Application Accepted By C! r Date 7/y Area Employee ID# r1f <br /> Grout Inspection By Date '❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Reptpft <br /> COMMENTS <br /> r <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Regnest# <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1127/2005 <br />