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WELUPUMP PERMIT <br /> r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> (N m <br /> JOB ADDRESS L• � CITYIDP ? ^� <br /> ICROSSSTREET APN - -�'- S. NDUSEAPPDCATI0X# F <br /> OWNERNAME rr I - <br /> OWNERADDRess C—ISTATEMP :y 7 <br /> / ill / • �( <br /> CONTRACTOR H <br /> CONTRACTOR ADDRESS ) ' (. CITYISTATEJAP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS /CITY]SSTATEOPP <br /> LICENSE (!CSI n.C-61 :"'.D-09 n Other NuMBcR45; y 61 V EXPIRATION DATE <br /> GEOGRAPHICAL 1 TION: Coordinates X Y Township_ Ranga Section_ <br /> INTENDED USE 5rDomestirlPrivale E:InigafloNAgdcvltural D industrial ❑Water Quality Monitoring 3 Soil Sampling/Characterization <br /> L'Public Water System <br /> 11 rent Inn owrnr. wow bwern Narne CbrOaCtane or r*Nun=r <br /> TYPE OF WORK JVNewWell Replacement Well E Well AlteratiorVModi&ation Q Other_ <br /> r,Monitoring Well(s) #of wells -Soil Boring(s) 'or i rt Geotechnical 9 of boxings <br /> ut-Of-Serdce Well E:Out-Of-Service Well Renewal i Cmss•Connection Repair <br /> if"New Pum -i Pump Replacement C Pump Repair 7 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method G Mud Rotary _Air Rotary -Auger _ Cable Tool o Push PP F Other <br /> Proposed Well Depth ,Nr� ft F—vation_��in diameter ='Open Bottom 3 Gravel PaddGravel Sze in diameter <br /> Conductor Casing in diameter / Conduct9r,Casing Dep ft <br /> Well Casing DiameterV in Thickness/Gauge/ASTM Sdred -ySteel I/p�sbe n Stainless�/�,al ri Other <br /> Grout Seal Depthft D Neat Cement(941b bag/5-10 gal wafer! rl Sand Cement I L "l sack mall gal water <br /> Sent rite(2p%solids) El Other <br /> Grout Placement Method um 2 Free Fail G Other 'Retardant/Accelerator(name) <br /> E E3TAL Installed By VDriHer il,Pump Contractor r t Other fJ <br /> C rete Pedestal nDimensfons:Width it Length R Thick in -1 Christy Box -1 Stove Pipe `�l'o G3� <br /> PUMP Submersibleu Turbine 7 Other HP Pump Sel R Standing Water Level <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN II <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS- I ALSO CERTIFY THAT MY REQUIRED LICENSE IS I <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENS I-AWS. <br /> MINI UR ADVANCE NpTiCE REQUIRED FSPECTIONS-PLEASE CALL(209)9 -769 <br /> Sit. OQ {Tm.E DATE <br /> I 1 1# <br /> 1111 1 Ill - I <br /> Jill Jill , I ill I I FT- <br /> [-Jill I ill <br /> clic ' <br /> DEPARTMENTUS ONLY <br /> Application Acca ged B ,- Date Area q EmpI.yee IDS ��17 <br /> Grout Inspection "" T c• - L Data E-- f ❑ SPECIAL Well Permit <br /> Pump Inspection By Date f`. r C WAIVER Received <br /> Soil Boding Inspection By Dale Constructed We cath It <br /> COMMENTS <br /> / , <br /> E SC ReceivedC AmountO°ta perm,t, Invoice WeIIIDS <br /> Codes Info B Cash Remitted 3ervlceR uestrK <br /> �o S� •� 11117 p 7 <br /> Alos,"* 1 <br /> ERD 43-M <br /> uaWt4 n /� �03 15-0 % WELL rrDNP PERrarr <br />