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i <br /> WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3°D FL-STOCKTON CA 95202 - (209)469-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-;697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS c 230 U J. V 1 A-LIE - CrrYIZIP CJ i}J�_ OZ 1 g <br /> v <br /> CROSS STREET Ys PN (i t�� PARCEL SIZE LAND USE APPLICATION# y <br /> V `/ y <br /> OWNER NAME �{' - PHONE 4J�_/` <br /> OWNER ADDRESS © "lJ + L ' C[TY/STATE/ZIP7��1c <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/S ft fil—r H' F � 1 1 - <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS 0TY/STAT11/h !Yn Iit may have expired without <br /> work bgQW4W ?4ed or inspected <br /> LICENSE [3C-57 13C-61 ❑D-09 ❑Other NUMBER <br /> OX .,!, rOnm-- ealth C ;,ion <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Owns Ip <br /> INTENDED ❑Domestic/Private ❑Irrigation/Agri'c'ultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water Systern Narne Contact Name or Phone Numberr <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> #of borings 11 Geotechnical of borings <br />€ <br /> 13 Monitoring Well(s) #of wells ❑Soil Borings) <br />! *Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pume Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> l Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft Q <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other W <br /> Grout Seal Depth ft ❑Neat Cement(94 1h bag/5-10 gat water) ❑Sand Cement sack mix/7 gal water C <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted ((�� <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) C <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other 1 <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe �'I <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set It Standing Water Level ft f1 <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN J� <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 /> I WORKERS COMPENSATION LAWS. <br /> MINI MU 24 HOUR ADVANCE NOTICE R UIRED FOR IN ECTIONS <br /> SIGNEDAn., TITLE DATE / <br /> ii <br /> I <br /> -1 <br /> ID <br /> TY <br /> A d P TA <br /> �. A41M <br /> M <br /> _ D.EPA.RTMENT. SE ONLY . <br /> ..-„ �.�--- K..f,..� ._,.,,�•w,;N.- -+--+.-..i'- - �-. 743- ��..r. <br /> Application Accepted By Date ��5 Area Employee[D# s9 tCY Q <br /> Grout <br /> �Inspection By Date [3 SPECIAL Well Permit 7 <br /> nIp'In ion By Date 13 WAIVER Received <br /> < <br /> Constructed Well Depth ft <br /> COMMENTS P�� �t.�n/ L l;c��cc_ t S ���/�O�! to IGT L7aE>�P. (JuJr� .� curt c- yEraOSts C+Er<ANT <br /> f <br /> PE I SC ReceivedChet Amount Date Invoice# Well ID# <br /> Codes Info B Cash emitted ice'R nest# <br /> q3� - zt73 lao.oec7 't` 05 P db4l-7` 8 <br /> PERMIT <br /> 56 <br /> imnoos � � <br />