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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 <br /> L NON-REFUNDABLE PERMIT _ CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS A105—i��,�—"���/���'{//W�� �� 'n r cirymIP tQ�KO� I�/ZV SD <br /> CROSS STREET Vhj1 /,�.E{KAIN` hI APN 426S-Z4lld-o PARCEL SIZE X 0 LAND USE APPLICATION# x <br /> OWNERNAME E� a7l,J-�C (�f��/�(�� �P�HON�E���(0 s's-Irw run <br /> OWNER ADDRESS 17_�✓� yfswlrz. OIL1( CITY/STATE/ZIP �iOtl( 4A '?5*7'40 <br /> CTL'-�, L_-�Ak PHON(.I?��_$_3 9-te a <br /> r <br /> CONTRACTOR ADDRESS ZyZ-Aj'LM�',/{ CITYISTATE/ZIP_ <br /> SUBCONTRACTOR _A�15•,t>.. �-/-'"—f PHO/N_ � 1,/SUBCONTRACTOR ADDRESS Air(J 55 �,I� AA CITY/STATEIZIP <br /> i <br /> LICENSE C-67 W-61 0.09 �yOther NUMBER"oMjr EXPIRATION DATE r�_ a✓� <br /> GEOGRAPHICAL INFORMATION: Coordinates X§!*7rfj,15 Y ,i/4-0010p Township— Range Section_ <br /> INTENDED USE Domest c1PrIVBte Irrigation/Agricultural Industhal Water Quality Monitoring X.Soil SamplinglCharacterization <br /> Public Water System <br /> If 61- <br /> 1—OwnerWnor toy$tt. eme on ac .—or Ione um cr <br /> TYPE OF WORK New We 0 Replacement Well Well Alteration/Modification Other <br /> Monitori Ig Well(s) #of wellsoll Bodn s °°}bonnpe z of barimg' <br /> 9( ) �_ Geotechnical <br /> Out-Of- ervice Well Out-Of-Service Well Renewal Cro c o C:'4 'Mas <br /> may, <br /> New Pup Pum R lacement Pum Repair Rais <br /> I L-1 11vill I LWA <br /> INK �� <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other I. <br /> Pm*ww-twvex Depth ft Excavation _in diameter Open Bottom '4r�911 h.2U0 1{1V wittmi} <br /> a.ir W&- Conductor Casing in diameter I Conductor Casing Depth fl �J T�TV-VA ti1`llpr(/s1 (/� <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel Plastic Ig 0h?�� #� lnS�@Ct�d <br /> Grout Seal Depth ft Neat Cement(9416 bag/S-f0 gal water) Sand Ce nt ser, ml al water <br /> Bentonk (20%solids) Other p I �lVIS011 <br /> Grout Placement Method Pumped Free Fall Other R tardant/Accelerator(name) �,J Division <br /> 1 <br /> PEDESTAL Installed Driller Pump Contractor Other <br /> Conor-t Pedestal Dimensions:Width ft Length _ft Thick in Christy Box Stove Pipe <br /> Pmt e Subm ible Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THA I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDI ANCES, STATE LAWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE H THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATIO LAWS. <br /> MINI UM 24 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9 3-7697 <br /> SIGNED 141--11-1 <br /> TITLEpJKiry�/ Kl�^ DATE <br /> III 77r I <br /> My <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date_ �� 'C Area Employee ID# <br /> Grout Inspection By Dale _ SPECIAL Well Pennit <br /> Pump Inspection By. Date WAIVER Received <br /> Soil Boring Inspection By. Date Constructed Well Depth ft <br /> COMMENTS_ <br /> PE SC Receiv d hec"I Amount : Date 4 Permit/ Invoice# WeI11D# <br /> Codes Info B Remitted Service Request# <br /> X41 It�� �0$'� 3Fi So r IL 6 15� <br /> FHD l:W,A <br /> 4-:31111 WELL(PUMP PERMIT <br />