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r t 1 it a tV <br /> 2- <br /> WELL/PUMP <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HA2ELT0II AVENUE•STOCKTON CA 94205•(209)460.3420 <br /> NON-REFUNDABLE PERMIT <br /> {rte, CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS- ✓ V • IG G'�: CITY/ZIP \jZ�,.� I( r,� �� <br /> CROSS STREET WAGAP'N O�DARCELStZE LAI?o UsEAPPLicATioNN <br /> OWNER NAME `• It-I("�-4-KPHOHax—( E`�o f 2 i�j I <br /> OWVER ADDRESSZ&2 <br /> CITY/STAT&7IP1.. "�' <br /> DA <br /> �— <br /> CONTRACTOR 1 A` A .T1� �]�(`II•I�I�1 << �`� L^r 1 ,11 Yl t AX <br /> tPHx. � L�. M,., <br /> CONTRACTOR ADDRESS 1�-f CRY/STATE2'P �Vl "� U V P'T � <br /> rJ)- 6r <br /> SUBCONTRACTOR 1V 1 PHONE <br /> SUBCONTRACToRADDRSSS CITY/STATERIP <br /> I <br /> LICENSE 47 L 0$1 U D-09 U Other NUNBER ExPiRATion DATE <br /> GWORAPHlOAL INFORMATION: Coordinates X Y Township_ Range_ Section_ <br /> 111TE140ED USE Domestic/Private 7 Irrigalion/A®dcaural 0 Industrial :3 Water Quality Moniloring C Soil Sem pling7Characterizallon <br /> u Public Water8yyalem <br /> Ildl(erent from OAner. vw4of ema or Fh6rW N.MW <br /> TYPE OF WORK �<Naw Well Replacement Well u Well AllerationlModificatlon u Other <br /> ❑Monitoring WeX <br /> N of wb6s D Soil Boring(s). 0 of bodnas ■of bodn�r <br /> ) 0 Geolechoical. <br /> ❑Out-0f-3ervke Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> u New Pum m Re lacement L Puu Pump Repair u Raise Wel CasIrti <br /> WILL CoNiTsUrTION <br /> Drilling Method Y Mud Rotary C AV Rotary C Auger l]Cable ToOt 0 Push Point U Other <br /> Proposed Well Depth 2� () R Excavation. 1 L In diameter U Open Boll u Gravel PecWGravel Size in diameter <br /> n Cond rGesl In diameter 1 Conductor Casing Depth aft <br /> Well Casin . amater In Tickneess 1G eIASTM Schad Spf_L24 n Steel klastic n Slalnless Steel -1 Other <br /> Growl eat Depth T C Neat ment(94 lb bao-10 gal water) Cl Sand Cement sack mW7 gal water <br /> KBentonite 20%solfds) L Other <br /> Grout P cemenYMethod' Pumped O Free C Other gRetardant IAccelefalor(name) <br /> ED T ncial4ad4Py--j Dril er Pump Convector ] Otter <br /> .0 COncretePedestal ODlmenslons:Width—it LerVjh RThIl k In O ChrlatyBox D Steve Plpe <br /> Epa DSubmeriNbleJTutbIne COlher HP 'Pump3el tt Standing Water Level tt <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN j <br /> JOAQUIN 00 DINANCES, ATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT A C TV WITH CA .ORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM 1N COMPLIANCE WITH ALL <br /> WORRE f E ION LA <br /> I I U ED FOR IN`SPEE TON P EASE CALL(209)963.7697 <br /> SIONE TITLEV \ DATE <br /> i <br /> N COJ <br /> � 2W <br /> ` QO <br /> U <br /> O 0�= <br /> S <br /> i <br /> `A TMEN%E , YApplication Accepted Ry Data Area Employae 1Dttv1j0Grout Ingpecuo i'By DataD Pec1AL Well.Permit <br /> Pump]nspecllon By DgteD, WAIVER Received <br /> Soil Boring Inspecllon By Date Co tructod Well Depth H <br /> COW.IENT5 t(� <br /> r <br /> PE SC Received Check#/ Amount Dole PermlU Involce0 4leIl1DY <br /> Codes Into B Cash Remitted ServlcoR west# <br /> ',v a' <br /> EM 07 WELL MW FER.VIT <br /> lgerl2 <br />