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�2-c-�3� WELLIPUMP PERMIT ✓, ✓ <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue.STOCKTON CA 95206.6232 - (209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL X209)953.7fi97 l=OR IN_SWECTIONS EXP(PZES I YEAR FROM DATE ISSUED <br /> JOE ADDREss / _ 0 <br /> —1051 vSPERRY RD. CIrr21P m <br /> CROSS STREET ARCH &AIRPORT WAVN q � D <br /> N- 1 7 7- .g-(7 9 pARCF.L SIZE � 0 <br /> 9 (_ __>_2A-90D USE ACP�PCLrcAnoN <br /> OWNER NAME TM FACT F -CSC J ISI ;N(C(/)l l}{ICI/",U�/1�( PHONE_ "l "►,L i�`1 �1� N <br /> OWNER ADDRESS SAME Sz�C) �t�j/,e�y�J pu/-1h CITY/STATE(Z!p_f,A Q() 5/ � <br /> CONTRACTOR --__ ?e t~a p=p GZ,nC,KTn Ar2MATTTRF MOTOR rrnrs <br /> �� M16Z'0__209-466-96 <br /> CONTRACTOR ADDRESS 646 S. CalifOrn.ia Street <br /> CITY/STATE2IP S1:OCktOT1. CA 95203 <br /> LUEONTFZACTOR <br /> PHONE _ <br /> oTRACTORADDRESSSE G C-57 ' C•61 0 D-09 0 Other NUMBER 724778 <br /> GEOGRAPHICAL INFORMATION: Coordinates X EXPIRATION DATE 08�� <br /> Y Township Range Section <br /> srrENDEo U sr- 0 pomestic/Private }p}{rrigation/Agricultural 0 Industrial 0 Waker Quality Monitoring 0 Soil Sampling/Charactorizafion <br /> r Pubfrc Water System <br /> ! If different from Ovint,r: a nr,ys em ame r <br /> one ame or ono um er I( <br /> TvPe-OF.WO, Rrc �, New Well 0 Replacement Weil Q Wei!Aitaratron/ModHicatfon 0 Other <br /> U Moniroring Wells) #of Wefts u Sof/Borfng(s). of borinros <br /> Out-ofService Weil C Out-Of-Service Wel!Renewal �'entechn/cal A 9(�gSS <br /> 0 NewPum, p ��mp Replacemump onk 0 PRepair 0 Cross-Connection Repair �c • IAC <br /> V�LL CONSrRUCT10N 0-Raise_Well Casin <br /> Drilling Method C Mud Rotary 0 Air Rotary 0 Auger 01 Cable Tool 0 Push Point 0 Other SEP 1 <br /> Proposed Well Depth it Excavation <br /> in diameter 0 Open Bottom U Gravel Pack/Gra �U n diameter <br /> G Conductor Casing—_Y_._.r in diameter / Conductor Casing Depth <br /> Wall Casing Diameter____ in Thickness/Gauge/ASTM Sohed ft �iRQ �UIyJy <br /> HEALTH NMFN7AL <br /> Grout Sea! Depth ft 0 Steel p Plastic © Stainless Steel 0 Oth QART <br /> C7 bleat Cement(94!b part/g.9p gel water) 0 Sand Cement-"" <br /> 0entonite(20%, <br /> 20%solids) 0 otherw__ sack mix17 gal water i <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other <br /> 0 Retardant/Accelerator(name) <br /> PEDEsrAL Installed By 0 Driller 0 ('urnp Contractor 0 Other <br /> C Concrete Pedestal Dimensions:Width <br /> _ ft Length_ ft 7 hick in G Christy Box 0 Stove Pipe <br /> P��P __ tmersible0 Turbine G Other ���� <br /> Set <br /> I HEREBY CERTIFY THAT IHAVE PREPARED g Water Level, <br /> THiB AppLiCgT10N AND p T THE WORK WILL BE DONE NnACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. ( ALSO CERTIFY THAT MY REQUIRED LICENSE S <br /> CURRENT AND ACTT ITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE tNtTit ALL <br /> WORKERS CO NSATION L S, <br /> M11 'MUM 24 HOUR ADVANCE NOTICE R QUIRED FOR INSPECTIONS <br /> SIGNED <br /> TITLE CEO <br /> NOTE: '" <br /> PUMP SET&STANDING WATER LEVEL 'lump well Is located approx. <br /> 04.04 ft.from Bridge, <br /> IS UNKNOWN UNTIL THE JOB IS DONE <br /> Tonal in Inserts <br /> bridge <br /> bridge <br /> i ' <br /> Location of pump R > <br /> pump <br /> E P R w v .------ <br /> :.. <br /> -"`,P0cMbon Accegtecf By / <br /> Grout inspection By ------ Date -{------- <br /> Date Employee!D# <br /> Pump Inspection By t 1 r � Date SPECIAL Well Permit <br /> Soil Boring inspection By WAIVER Received <br /> COMMENTS Date . Constructed Well Depth <br /> ff <br /> PC Sc Received <br /> Codes Info Checloltl Amount <br /> t3 CashDate Permit( <br /> Remitted Service Re nest# Invoice# <br /> QSo 3/���' � q well lD# <br /> CHD 43.08 <br /> 8/04108 <br /> WELL/PUMP PERMIT <br />