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A JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DEPT <br />)N -REFUNDABLE PERMIT C <br />WELL/PUMP PERMIT <br />1868 East Hazelton Avenue - STOCKTON CA 95205.6232 - (209) 468-3420 <br />I -L (209) 953.7697 FOR INSPECTIONS EXPIRES 1_YEAR FROM DATE ISSUED <br />9ADDRE89 22176 SKIFF RD. Crry/zlp ESCALON 95320 <br />.OSS STREET VAN ALLEN - APN <br />VNER NAME <br />;CTL SIZE 158 LAND Use APPLICATION # <br />PHONe 209 652-5009 <br />VNER ADDRE33 SAMA' CITY/STATC/ZIP <br />,NTRACTOR D21ta Pum, GTnry rnN ARMA RF <br />L TU R <br />MoTQC WORKS fa@!. -_209-466--962 <br />INTRACTORAODREnB 646 S. "California Street CITY/STATE/ZIP Stockton, CA 95203 <br />13CONTRACTOR PHONE <br />SCONTRACTOR ADDRE63 CITYBTATE/ZIP <br />JFNSE 0 C-57 C-61 0 D-09 C Other <br />NUMBER <br />EXPIRATION DATE 08/ <br />tOORAPHICAL INFORMATION. Coordinates X Y Township Range Section I <br />rENOED USE 0 DOMestic/Private j��rrigatlon/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different tram Owner: VVGW <br />• NAMG &PP1046 Nuffllior <br />Pa of WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other Z AYA <br />_� <br />0 Monitoring Well(s) # of wells 0 Soll Borin s or borings 4 or �F/� <br />Boring(s) O Geotechnice! � <br />0 Out-Of-Servfce Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair CI <br />0 New Pumn ❑ plimm Ra lacement m Re air 0 Raise Well Casing AP <br />'LL CONSTRUCTION <br />filling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 OtherUCAQU <br />opoaed Well Oapth_ft Excavation In diameter 0 Open Bottom 0 Gravel Pack/Gravel Size ALT N'1 <br />0 Conductor Casing in diameter / Conductor Casing Depth ft Tjyj` <br />Well Caving Dlameter In Thicknese/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft 0 Neat Cement (94 /b bao-10 ga/ wate)-0 Sand Cement sack mlxf7 gat water` <br />0 Bentonite (20% solids) 0 Other <br />'out Placement Method ❑ Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) I <br />MESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestaj Dimensions: Width ft Length ft ThickIn G ChriQ Box 0 Stove Pipe I <br />ubmersible0 Turbine 0 Other hip3 Q Pump Se ft Standln er Level ft <br />HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN AC OkDANCE WITH SAN <br />)AQUIN COUNTY ORDINANCEJ, -STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />1RRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT .I AM IN COMPLIANCE WITH ALL <br />ORKERS COMPENSATION LAWS. <br />" flit t ? ,tlr 11!/3.411t'f* <br />hie), <br />.Fi'ii 6it.E�t:} t-lii2 fhl;�Mf�:f:`t'fUiVS I <br />�KiNED_ a — TME ,('m DATE I <br />p---- T E N T U E ONLY <br />Application Accepted By f Data ?� Area Employee ID#k#—IW <br />GrOLft InspeCtlpn By _ Date PEClAL 1fVe11 P@R11It <br />Pump trtspaclon BY Date WAIVER Received <br />S0A Boring Inspec don By Data <br />COMMENTS Construa cl! Well Depth ft <br />Date rvrrrvv ittvoiee S1 WeH EOaii <br />8srvf00 ta6st � <br />Lor) <br />i <br />EMD 4&06 <br />6/0410a <br />WELL PUMP PERMIT <br />