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_ WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 962054232 -(209)468-0420 <br /> NON-REFUNDABLE PERMIT CALL 209p 953-7697 FOR INSPECTIONS GEX.PIRES 1 YEAR FROM DATE ISSUED gyp <br /> Joe ADDRESS It f�l�E-1 S C\cl nGr �fr..a.r�� (� CrtvlbP &cxa ko Yt —1 5 3 2-- <br /> CROSS STREET 1 � ) M✓ APN 2-�9-7 SO Jt11 PARCELSVE I0.OI LAND USE'SA` Z•PPLICATION* <br /> OWNERNAME I+CS I,IC GLrrin PHONE 0 -o8'tip S <br /> OWNER ADDRESS 1-1941 SC\C1rGra- CITY/STATERIP E5caillon t C& 95-3 <br /> CONTRACTOR t D �1y `_• \`- PHONE5l'IS—It%5 <br /> CONTRACTORADDRESS QG\Qr�wIC A.l C. CT'/STATEIL �/� <br /> P 11\n&4_-3C-4 J) I C& 'IS36(' <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEI21P LICENSE -C47 C-61 0-09 i Other NUMBER z9.oe,D E%PIMTION DATE 6'3 1^0+ <br /> GEOGRAPHICALINFORMATON: Coordinate.X V TOWnship Range_ Secgon_ <br /> INTENDED USE omestic(Pnvate -Irrigation/Agncufturel I Industrial 1 Water Quality Monitoring Soil Sampling/CharaGenzabon <br /> unbnavina.Dcw.,m i orrectfa..rlho.Nu r <br /> TYPE OF WORK New Well YReplacement Well -: Well Afteration/Modification Other <br /> Monitoring Wels) #of wells Soil Bodng(S) #Mbonnps Geotechniwl #al mniq. <br /> Out-Of-Service Well Out-Of-Service Well Renewal ❑CmssConneceon Repair <br /> -_ New Pump Pump Replacement Pump Repair ❑Raise Well Casing <br /> WE LCONSTRuCTON <br /> Drilling Method Mud Rotary Air Rotary F Auger Cable Tool i-Push Point Other <br /> Proposed Well Depth 24 O IT E...don j'• _in diameter a Open Bottom Gravel PaWGravel Size fM/&_in d1eDMter <br /> Conductor Ca in diameter / Conductor Casing Depth It <br /> Well Casing Diameter n TIn ness/Gauge/ASTM Schetl t�a0 CA- 0 Steel T vatic -.Stalnlesa Steel Other <br /> Grout Seal DepN It Neat Cement(941b bag/5-f0 gal water) ❑Sand Cement sack mix/7 gal water <br /> e tantte 0% as) 5 Other <br /> Grout Placement M o0 pad Free Fall Other !Retardant/Accelerator(name) <br /> PED�TAL Installetl By �Driller ump Contractor Other <br /> Concrete Pedestal Dim SIOna:Widgl_ft Length ftThick in Christy Box _ Stove Pipe <br /> PUMP Submersible. Turbine -1 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 /> MINI UM 24 HOUR AD NCE LREQUIRED FOR INSPECTIONS p <br /> SIGNED 1 I J\7�CrV)SOr DATE <br /> 1 <br /> AYMENT <br /> ECEIVED <br /> G 17 2012 <br /> t JOAQUIN COUNTY <br /> NVIRONMENTAL <br /> TH DEPARTMENT <br /> Eel P- <br /> Af <br /> PA 2TMENT USE ONLY <br /> Application Accepted 1� Area Employee ID# <br /> Grout Inspection By &-1 Date L'A 2� SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER ReCelved <br /> Soil Boring Ins ton Date cted Well Depth ft <br /> COMMENTS $ <br /> PE SC I Received LQURGKW Amount Date FrermlU Invoice WeII ID# <br /> Codes Into B CashRemitted ServiceR oast# <br /> 2-70(--3 41. t7 t o Z <br /> FXo�9Ca WIILNUMPPERMIT <br /> 6DI/M <br />