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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> m <br /> JOB ADOREss /J rrIt �1 Cm21P„ 'DC� CA: OV 9 <br /> CROSSSTREET WVA Plcza APN`,I/Td32 lyf PARCELS¢E L//A�tND USE A�PPI�U�C/[AJnO�M/1t <br /> OWNER Nme // r M T'VIPHOXE�)I dD -5a(n 9 <br /> OWNERADDRESS 0. I qql - ` A Cm/STATEIDP � I� t� '?5,2 P? <br /> R <br /> Coi cnOR Veil 0. kr(di rtI!ln /t.SS0a'a fcSII P 0]31'0 <br /> �HONE (;0 <br /> CONTRACTOR ADDRESS A�1 YNkU S'Yn QI WaY Cm/STATEIL ✓ <br /> P edf', Cy� Q�a yl3 <br /> SUBCONTRACTOR ' PHONE <br /> SUBCONTRACTOR ADDRESS Cm/STATE/LP /1�J <br /> LICENSE G-57 iC61 D-09 - Other NUMBes bgeDy E%PIRATIONDAm tom• <br /> GEOGRAPHICAL INFORMATION: COOrdlnateaX V Township_ Range_ SecUcm_ <br /> INTENDED USE Domestiopmrste t Imgation/Agricu0uml c.Industrial n Water Quality Monitoring - Sal SamplinglCharacter'vation <br /> Public Water System <br /> IfdittemMhom OWlMr'. eN ye Bm ams emom a NumKr <br /> TwE OF WORK New Well - Replacement Well Well Aheration/Modification - Other <br /> Monitoring Weli(s) pofwells f. Soil Bonng(s) Pef eon's IX6.1achnical RMlxm�a' <br /> Out-Of-ServiceWell I Out-Of-Service Well Renewal Cross-Connecdon Repair <br /> New Pum Pump Replacement C Pump Repair r Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary i Air Rotary Pquger I Gable Tool I'.Push Point C Other <br /> Proposed Well DepthjQ-1 SIt Excavation q-q in diameter r: Open Bottom I:Gravel Pack/Gravel Sim in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/GaugelASTM Schad Steel C Plastic '.1 Stainless Steel ❑Other <br /> Grout Seal Depth ft Neat Cement <br /> - I'Sand Cement /n gs,}L( gal water <br /> 'I s <br /> Gardenia X4Other' r-I'f PIQ% IF us <br /> Grout Placement Method i Pumped Free Fell li Other a Retardant Accelennor(name) <br /> PEDESTAL Installed By Driller ❑Pump Contractor c Other <br /> Concrete Pedestal"DImenslons:Wkfih_ft LmgM hick in Christy Bax i'Stow Pipe <br /> PUMP - Submersible Turbine F Other HP Pu et N Standing Water Lewl 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 /> MUM 24 HOUR ADVALNC OTICE REQUIRED FOeR,INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE rLII -T C DATE <br /> - DEPARTMENT USE ONLY / <br /> Application Accepted By Data Area L( �( Employ.lDk� `v � <br /> Grout Inspection By D to ElSPECIAL WBII Permit <br /> Pump Inspection ❑ WAIVER Received <br /> Soil Boning les B FIR Constructed Well Depth N <br /> COMMENTS J&e--,!5 A <br /> l//7-7ZgIf5 <br /> PE SC ReeehedC Amount Date Invoice Involve 11 Well <br /> Codas Info 8 ash Remitted ServicaR ueste <br /> l5� 8-4D i1Z S <br /> EHD 4306 WELL HUMP PERW <br /> Ori Q <br />