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WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTT ENVIRONMENTAL HEALTH DEPARTMENT 186E EAST HAZELTON AVENUE - STOCKTON CA 95205 - (2091468-3420 <br />NON-REFuNDABLE PERMIT - CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />rAt" Fid &V�d C.T. Mar�T ` cyK4c,0, _ <br />JOB ADOREee �1biAY'iX� ��t.ITyILP ,� <br />CROSS STREET JJ AP P ARCEL SJ -ME A 7 LANG UBE APPLICATION M—_„' <br />, —N <br />OWNERNAME Cr �� $R <br />DOS � las d 2 Td 34(9,. TATEIZW rr��rr�_ - ` 1 , c A <br />OWNER ADDRESS • PP16 f ' 11 --yo- <br />1 <br />r <br />CONTRACTOR r kIk �r� ("}PHONE. 1iF-(59 -yo —/`r <br />CONTRACTOR ADDRESSjj�B �_I CRY)STATEIZIP DCI 1 4 ^A 9stl�7� l •`� <br />$1 CNTRACTORADDRES v � CRYISTATEmp L&gs: = ra <br />/ Q <br />LICENSEE )ZC-57 :1C-61 7 D-09 ] Other _ _ _ NUMBER-�ATtON � EKPIRDATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y TownshtB Rana* A—H.. <br />INTENDED USE -1 Domestic/Prlvale 7 Irrigation/Agricultural 7 Industrial O WaterQuality Monitoring ;"Il Sampling/Charecteriration <br />7 Public Water System <br />N dlRerer, from Owner: Walar or <br />TYPE OF WORK ] New Well 7 Replacement Well Well AlterstlonlModNlcation 7 Other <br />Monitoring Well(s)_=__ _, #ofwe0a = SolBodng(s) Nafbodnes XGeotechnical_ embodros <br />7 OU14XService Well = Out-OfServlce Well Renewal ] Cross -Connection Repair <br />New Pun_Lt__ ] Planp R unk acemenl PRepak 7 Raise Well Casing <br />LL <br />WECONSTRUCTION <br />Drilling Method 7 Mud Rotary 7 Air Rotary Nf.AAQer ] Cable Tool 7 Push Point 7 Other____,__ <br />Proposed Well DapOn j1Y- I fl Excavation 6 in diameter D Open Bottom 7 Gravel Pack/Gravel Size In diameter <br />7 Conductor Casing In dlemeter / Conductor Casing Depth <br />Well Casing Diameter —In ThlckneWGauge/ASTM Sched 7 Steel J Plastic 7 Stainlxss Steel 7 <br />Grout Seal Depth tb-15 It Neat Cement (94/b bag3-109a/waler) 7 Sand Cement__, __ sack mlxl7 gal weter <br />7 Bentonits(20%solids) 7 Other <br />Grout Placement Method 7 Pumped AFreeFall ] Other _ 7 Retardant/Accelerator(name) <br />IPEof ESTAL Installed By 7 Driller 7 Pump Contractor 7 Other <br />:J Concrete Pedestal 701manalons: Width_ R Length ft Thick , in J Christy Box 7 Stove Pipe <br />PUMP 7 Submerslble7 Turbine Ther HP Pump Set R Standing Water level fl <br />1 HEREBY CERTIFY THAT 1 HA EPD THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDIN S, ST WS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURREFr=1111111; <br />ACTIVE H THrVAW7'N0T11CF <br />IA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKEENSAI LA //�'� / <br />UR A REQUIRED FQIi"F,9TJQn! PLEASE CAL ('2 9)-914X-7687,--") <br />.jV <br />00�Pyti��i <br />�oPo�v <br />D P RT NT U O L ll <br />Application Accept ate Area CEmployeel0#�arr-rJ <br />Grout Inspection By _ i - ❑ PECIAL Well Permit <br />Pump Inspection By Date ❑ WArm Received <br />Son Boring I By Dale Car tructed Well Depth ft <br />CAMINENT9 `�% s0�� 7 <br />42 <br />M; <br />WELLIPUW PERNn <br />log <br />*"elm <br />M; <br />WELLIPUW PERNn <br />