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�n1k'wl 5 w n 30 1b ,9s, <br /> WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT 'A n CALL 209 953-769 FOR INSPECTIONS EXPIRES I YEAR <br /> /'FROM <br /> ��]DATE ISSUED <br /> Joe ADDRESS , + "r', ` 1 r1 o u CfrY/ZIP u fO• l (C4 1 "` D <br /> O <br /> CROSS STREET . APN PARCELSUEja?=�4ANDUSIAPPUCATION# <br /> OWNER NAME {//,�'" ,/� 11 LA /` jPHONE <br /> OWNER ADDRESS <br /> :2 '2 I O VV n V r CITY/STA P •� <br /> CONTRACTOR v l� PH E v <br /> G / 1) VjG <br /> CONTRACTOR AODI2E35 / V CITYISTA P �7-y'-�� <br /> SUBCONTRACTOR / PHON Y• r <br /> SUBCONTRACTOR ADDRESS / r'C1rry/'/S7(T1/ATTEMP'n /I C� <br /> LICENSE C-57 C-61 D-09 Other f NUMBER v 1 `+ �✓ O EXPIRATON DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE V61.1mestic/Pri Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If eilferent from Owner: water 5YSteM Name Uontad Name or 11hone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modificabon Other <br /> Monitoring Well(s) #cf Lceft Sol Beting(s) #of boanp GcataaM i ! #of borings <br /> IQL <br /> OicIm Re lacOut-Of-Service Well Renewal Cross-Connecton Repair <br /> Iz— <br /> Pu <br /> ement <br /> Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION r„ <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other �/�` <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth It Neat Cement(94 Ib begi5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other f� <br /> Concrete Pedestal Dimensions:Width it Length it Thick in Christy Box Stove Pipe <br /> PUMP V Submersible Turbine Other HP Pump Setft 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 /> MINIMU,M 24 HO DVNOTICE REQUIRED F(7� n <br /> INSPECTIONS-PL E CALL(209)_15,3-7697 <br /> ) <br /> SIGNED —L TniE)-M <br /> / ✓4 Ma� DATE L 3 II.(ark. <br /> n <br /> CEIVED <br /> PA'IMEN <br /> aECE" --AUG 2 9 2�1� <br /> 3 OOENTAL HEALTH <br /> p►uGo Roth+ RMIT/SERV(CES <br /> e <br /> NAexll @ <br /> �T: <br /> MENT U E OYnApplication Accepted Bv_ Data {' C/ Area q'C Employee <br /> Grout Inspection By Date L SPECIAL Well Permit <br /> Pump Inspection By Date I ld I WAIVER Received <br /> Soil Bonn,InspectI By Date Constructed Well DD�th ft <br /> COMMENTS r a Q(6p ff <br /> I PE SC Received Chee Amount Pr <br /> Codes Into B a fternitted Date Servic:Rmitl uest# Invoice Web ION <br /> X60 7�� W ro0 3� <br /> EHD+3106 WELL/PUMP PERMIT <br /> .130 r2 <br />