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WELL/PUMP PERMIT <br />SAN JOAom CouNlTY EHvimmi ffAL HEALTH Derr 1868 East Haze6on Avenue-STOCKTON CA 9SMS-6232 - (209) 468.3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7097 FOR INSPECTIONS ^EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe AuoREss eq . 1S�.tS}t/Ge�yL %ja .1f1� ^n c c mp 14c- j!y 6 93�?•2e <br />CROSS STREET V� {7 T APN OO S 1 2 O % PARm SIZE ' ;_LAND USE APPu MI, S <br />OWER NAME ISB ft'o t PHONE <br />OwNERADDREss 23Q98� /i� 4%. * W /Qi2)y7i��/ f C.TYISTATHz� /��L."i <br />R95:�a <br />CONTRACTOR .V 1V e/�/�aL SC7/US rU[i SEA'V�cE PHDNE 909 7* -S <br />CoNTRArTORAoDREss /016.? tir<w HOPE Cm/srATE21P_S�r�T eAF 9563.? <br />SUBCONTRACTOR PHONE <br />SUBCONTRAcToR ADDRESS CRYISTATEMS'' o �/ <br />L CEME XC -57 I I C-61 1 1 D-09 i I Other NumsER ;' { () _40 ExPtRAnoN DATE <br />GEOGRAPHICALINFORMAnoN: Coordinates X Y Township _ Range Section <br />INTENDED USE /ADomestidPrivate 1 i Ir igation/Agricultural 1 1 Industrial 1 i Water Quality Monitoring I i Soil Sampling/Characterization <br />i I Public Water System <br />adllrerord bpm Owner. r sysim Or Phone Number <br />TYPE OF WORK i t New Well i 1 Replacement Well I i Well Atteration/Modrfication i i Other <br />11 Monitoring Well(s) S of wells 11 Soil Boring(s) gor borUW l i Geotechnical tr or borings <br />i i Out-Of-3ervice Well i i OuFOf-Service Well Renewal i t Gross Connection Repair <br />1 i New PumD i I PumD Reolacement Al2unm Renair i i Raise Well Casino <br />Drilling Method i i Mud Rotary i I Air Rotary I i Amer 11 Cable Tool i i Push Point n Other <br />Proposed Well Depth ft Excavation in diameter i I Open Bottom i I Gravel Pack/Gravel Size In diameter <br />I I Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter _ in Thiclmess/GaugefASTMSched i i Steal i I Plastic 1 i Stainless Steel I i Other <br />Grout Seat Depth it 1 I Neat Cement (94 /b bag/5-10 gal water) i i Sand Cement sack mW7 gal water <br />i i Bentonite (20% solids) 1 i Other <br />Grout Placement Method I I Pumped I i Free Fag ii Other 1 I Retardant / Accelerator (name) <br />PEDESTAL Installed By 11 Driller I I Pump Contractor 1 1 Other <br />11 Concrete Pedestal Dimensions: Width ft Length ft Thick in I I Christy Box I I Stove Pipe <br />PUMP U.Subrnersiblel 1 Turbine 1 1.Other HP Pump Set 1i/ it Standing Water Level _ _ ft <br />1 HEREBY CERTIFY THAT 1 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 />SIGNED <br />24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />TITLE DATE 5--2.2-1 <br />DEPARTMENT USEL ONLY <br />AMUcation Accepted By Date rh7 -1 <br />cy�yrtrlspedion By ZET Date t o / j <br />Pump inspection By Date <br />Soil Boring Inspection By Data <br />COMMENTS <br />Area LL Employee ID# <br />SPECIAL Well Permit /f <br />WAIVER Received <br />Constructed Well Depth ft <br />WELL MUW PER0.;rr <br />41 <br />a <br />M <br />0 <br />m <br />!d <br />20 <br />11. HEALTH <br />VICES <br />0"11.4 FROM; <br />WELL MUW PER0.;rr <br />41 <br />a <br />M <br />0 <br />m <br />!d <br />20 <br />11. HEALTH <br />VICES <br />