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- 1A) l C <br />y C"-' I I -10 -R' 05,1 <br />WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />{r yCALL 209 953-7597 FOR INSPECTIONS EXPIKES 1 YEAR FROM DATE ISSUED <br />JOB AnilAnil�»� "' "' '- " ' W I (G: /'� CITYfLP /, L 1 f� die O <br />ey 1 C� ` ,7 R' <br />CROSS STREET IBJ S i� '� 11� Y RV APN- K DD PARCEL SIZE 24 6L;Al1 TUBE APPUCAnoN # <br />C ( 1 <br />OWNER NAME _ _J O) c� k%j'((PHONEI �Y-' /- 1r-7 C, KJ <br />OWNER ADDRESS - i J� V 1 j��',� �' CITYBTATEMP V Ci T , jC '{ 'l "1 � C' 5 <br />CONTRACTOR \ Lt 1 )i e y 1. J '� 1 1 1Qr '(i LI PI. 3 C 1 - '? 7 (7 9 <br />CONTRACTOR ADDRESS C' 13 C' X \ C.Y/STATE/ZIP G Ile' V 1 CA 61 7 lam-• S �� <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CRY/STATE/LP <br />LIcENSE C-57 M <br />C-61 _ D-09 _ Other NueER' <br />"1 J. EXPIRATION DATE 1 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Rangs Section_ <br />INTEMOED USE : Domestic/Private -)L Inigation/Agricuftural 7 Industrial - Water Quality Monitoring = Soil Sampingi/Characteraation <br />Public Water System <br />If of efew born Owner: r ante contia rimm Or Mone Rurmw <br />TYPE OF WORK New Well = Replacement Well = Well AiteratioNModificatiion = Other <br />- Monitoring Wel(s) # of wells _ SON BOting(s) a of bodnp = Geotechnical s of borings <br />- Out -Of -Service Well - Out -Of -Service Well Renewal - Cross -Connection Repair <br />Drilling Method)( Mud Rotary - Air Rotary - Auger - Cable Tod - Push Point - Other I �d <br />Proposed Well Depth 5(, QI't Excavation I_ in diameter - Open Bottom �4 Gravel PadUGravel Size_ diameter <br />Conductor Casing in diameter / Conductor Casing Depth R <br />Well Casing Diameter /� in ThidmesVGauge/ASTM Schad ,9Li' = Steel JT Plastic = Stainless Steel = Other <br />Grout Seal Depth 56 ft = Neat Cement (94 lb baW5.10 gal water) Sand Cement C sack man 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 7 _: Other <br />Concrete Pedestal -Dimensions: Width ft Length ft Thick , in - Christy Box - Stove Pipe <br />�t r� ubmerside - Turbine Other HP= Pump Set ft 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED /c'� �f c:ZZN-c• TSE V �C i (• C, NF1 T DATE <br />MEMNON <br />DEPARTMENT USE PNL <br />Application Accepted B Date <br />/�'�► �.Date SPE�CIAL Oil Peffnit <br />� <br />Pump Inspection Ew Date —5 D WAIVER Received <br />Soil Boring Inspection By Pate Constructed Well Depth <br />COMMENTS <br />RF Y4 f, <br />20 <br />c0416 <br />N�jq�[!jN <br />TNF q9� q <br />FNT <br />PE <br />Codes <br />Sc Received <br />Info 13Y <br />Check#/ <br />Cash <br />Amount Date <br />Remitted <br />Pormitl Invoice# WeIIID# <br />Service R uest# <br />i <br />W POU NO� <br />EHO 4348 <br />4130112 <br />WELL (PUMP PERMn <br />14 <br />