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Z�.i-ILti�� S cwr 1 �.�-i� 451 �✓ <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 0205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTIONS ( EXPIRES 1 YEARFROMDATE jISSUED <br /> JOB ADDRESS <br /> 13�b O• RnC Z <br /> CwP Uyltl� <br /> �/� {y Ly-� 1 -r Y <br /> 1/l3-YAC0-W.�P o <br /> CRO39$1HEET (APN AflLEL$¢E LAyKHO USE APPLICATI/yON�R# <br /> OWNER NAME ..// �P-YHYO'NE� �•^J�T1,�� LJ'r�J I UUDLrrr <br /> OWNER ADDRESS 5 1 O yy D DY/BTAT .P 1 O( �' • "I I /� <br /> CONTRACTOR Ik,C ` I9vr L ll.l V U PHONE k H <br /> CONTRACTOR ADDflESS 1 I CRY/ST, IP SZN, •' "• <br /> SUBCONTRACTOR N I r` PHONE <br /> $USCON7RAU0R ADDRESS C"/STATE/LIP 1' ,^. //�� <br /> LICENSE C57 LC-61 UD-09 UWhsr NUMBFA�l.Y KPIflATION DATE -1 �01 <br /> GEOGRAPHICAL INFORMATION: Coordinates)(_ Y Township_ Range_ Section_ <br /> INTENDED USE Domestic Pdvate C InigadonfAgriculturdl ❑Industrial D Water Qualay Monitoring C Soil Sampling/Chanecterization <br /> U em <br /> Pmne,.mko.m ne <br /> TYPE OF WORK I<NSW Well L Replacement Well a Well AlteratioNMadifiration a Other <br /> ❑Monitoring Well(s) Is of wells ❑Soil Boring(s) I'dw,i`M' D Geatechnical pof°otlro6 <br /> ❑Out-Of-Service Well ❑Oul-OfSmice Well Renewal ❑Cross-Connection Repair <br /> u New Pump L Pump Replacement a Pump Repair a Raise Well Cmin <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mudt II'��C Air Rotary L Auger -T]Cable Tool D Push Point ❑ Other <br /> Proposed Wall Depth UV ft Ezwvetion �J- in diameter a Open Boftam U Gravel Pack/Gravel Size in diameter <br /> n uc <br /> Condpr_Casing indiameter / ConcipatorCUIng Depth It <br /> Well CasingDiameter Y' in Thidmeas/Gauge/ASTM Sche _ n Steel (Plastic n Stainless Steel n ONer <br /> Grout Seal DepthIt L Nest Cement(94 lb bao-f0 gal water) ❑Sand Cement sack n W7 gal wetter <br /> VBentanite(20%solids) L Other <br /> Grout Placement Mathod3CPumped OFree Fall COther ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By T Duller C Pump Contractor D Other <br /> ❑Concrete Pedestal DDlmensione:WKBh_ft Length N Thick in ❑Christy Boz ❑Stove Pipe <br /> PuaP C SubmersibieD Turbine C Other HP Pump Set It 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 COU O INANCES, S TE LAWS, AND RULES AND REGULATIONS. t ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AN C WITH TH ALIF RNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORK EN A ON LAW <br /> 1 I 2 ED FOR INSP'EC IOnNS-1ypLEASE CALL(209)9 3-769 <br /> STONE TITLE uW K4 �r�� I• DATE <br /> 4NTAL <br /> T <br /> D <br /> 17 <br /> TY <br /> NT <br /> E,FA TM ENTSE N Y <br /> Application Accepted By ate DArea Employee lC#_� V <br /> Grout Inspection By Date ❑ PEC Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth ft <br /> COMMENTS <br /> PE SC I Rea lvedash =Amount Dale erviPermH/ Invoice! <br /> Codes Into B C .d ©SR� ce uest# Well TDO <br /> { <br /> EHD 4s06 WELLNUMPFERMn <br /> V3N1I <br />