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I ' <br /> 41,7 <br /> (,ri�'T- : v UMP PERMIT JI. <br /> AN.IOADUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTMENTI 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468 � L <br /> r NON-REFUNDABLE PERMIT CALL 209 953-7697 OR INSPECTIONS EXPIRES 1 YEAR FR DATE ISSUEIS <br /> • y <br /> �i <br /> JOB ADDRESS m <br /> 7a �� CITY/ZIP v vv 1 D <br /> /J 0 <br /> CROSS STREET `7 � APN Q/, (13e—3�PARCEL SRE •�V LAND USE APPLICATION# M <br /> OWNER NAME r,fr / PHONE d <br /> OWNER ADDRESS O •CITY/STATE/ZIP <br /> CONTRACTOR Q �/9,5//UG���N �GY�/�� � PHONE ,/�b <br /> CONTRACTOR ADDRESS Clrr/STATE/ZIP �/✓f�SN 2 S -/ <br /> SUBCONTRACTOR 1 PHONE <br /> /r/1 <br /> SUBCONTRACTOR ADDRESS '✓ CITY/STATE/ZIP <br /> LICENSE )fC-57 L C-61 a D-09 L Other NUMBER 7'96/6 6' EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Ja Domestic/Private 7 Irrigation/Agricultural G Industrial =Water Quality Monitoring L Soil Sampling/Characterization <br /> u Public Water System <br /> It different from Owner: Water bystern Nam on a amolPho-NUnribe, <br /> TYPE OF WORK XNew Well L Replacement Well L Well Alteration/Modification L Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well L Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> L New Pump L Pump Replacement L Pump Repair L Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary E Air Rotary C Auger 7 Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth_2&(Qft Excavation_(�in diameter L Open Bottom L Gravel Pack/Gravel Size in diameter <br /> ri Conductor Casing in diameter / Conductor Casing Depth. It <br /> Well Casing Diameter_,�,irl Thickness/Gauge/ASTM Schad 5 n'jag Steel )(Plastic F]Stainless Steel -i Other <br /> Grout Seal Depth �d0 �4 ft L Neat Cement(941b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> )(Bentonite(20%solids) L Other <br /> Grout Placement Method JXPumped ❑Free Fall C Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By -1 Driller L Pump Contractor L Other <br /> ❑Concrete Pedestal❑Dimensions:Width�z_ft Length ft Thick in ❑Christy Box L Stove Plpe <br /> PUMP ❑Submersible 7 Turbine E Other HP 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 QRDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND AC V RH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPE L�RADVAN <br /> S. <br /> MINI UCE NOTICE REQUIRED FOR IIJNNS�PECTIO S- L SE CALL(209)953-7697 <br /> SIGNED TITLE �� DATE <br /> SA16 99 <br /> 2-5 <br /> °gov,N cZ�16 <br /> CN 44 NAY <br /> DE ARTMENT US ON�Y <br /> e Z 7/ <br /> Application Accepted Date Area Employee ID# 't0 <br /> Grout Inspectio ate ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received \ <br /> Y Soil Boring in action By ate C nstruct Well Depth tt <br /> COMMENTS f — ���! r �� �'CY J <br /> 'moi 7r <br /> 11\\\!!! J r_ <br /> o- d SReceived Check#/ Amount Permit/ <br /> \� Codes Info Date Invoice# Well ID# <br /> B Cash Remitted Service Request# r <br /> EHD 43-0s WELL/PUMP PERMIT <br /> 4/30/12 /-57 7!J <br /> @vtN� r-��« �. J� �� Q hlkk�� 4 v\,M Q ��� �u'� ( b Nig DN,4 <br />