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yT� 5_c ' zkMt 5 �� t-( 62LL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA -95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT BALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />--.----- '7'77-7 to //T`4 f%,—r7.. 7/?)VjQ _53A <br />CROSS STREET C c�/I�I/�/ APN�Z�jSDQ—/3"/Q—/jI P�AR/CCEEL SIZE011e <br />LAND US"E <br />jAPPLICATION # <br />OWNER NAME PHONE <br />L/5A! C <br />OWNERADDRESS CITY/STATE/ZIP 50 FAM - _D "� <br />CONTRACTOR / Bf ✓ ibCJS Gl t��2 [yam — PHONE F511-37-10 <br />37-! 0 <br />CONTRACTOR ADDRESS �j �l�� "—�� CITY/STATE/ZIP iLl� <br />• r <br />SUBCONTRACTOR O�� �L-/� PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE <br />i) D-09 [1 Other <br />NUMBER <br />CITY/STATE/ZIP <br />EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range__ Section <br />INTENDED USE >bomestic/Private E Irrigation/Agricultural industrial r:; Water Quality Monitoring L1 Soil Sampling/Characterization <br />iI Public Water System <br />If different from Owner: Water System Name pct Name or Phone Number <br />TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitorin-Vee lls) # of wells 0 Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />0 Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />�MNew Pump n Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method <br />vlud ��Rl1otary ❑ Air Rotary ❑ Auger 0 Cable Tool LI Push Point ❑ Other <br />Proposed Well Depth�50 ft Excavation in diameter r_� Open Bottom y Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter � in is�r>� /Gauge/ASTM Sched dfk U Steel AAastic ❑ Stainless Steel 0 Other <br />w <br />Grout Seal Depth Neat Cement (94 lb bag/5-10 gal water) hO§and Cement Ao" sack miw7 gai wafer <br />&0 " 0-'A [I Bentonite (20% solids) 1 Other <br />Grout Placement Method - umped [] Free Fall C] Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By o Driller _; Pump Contractor 0 Other <br />Concrete Pedestal [_ Dimensions: Width ft Length /off ► ft Thick _ in ❑ Christy Box 0 Stove Pine <br />LPuMP MSubmersible❑ Turbine r; Other HP / Pump Set I*Z ft Standing Water Level _J�J --r-- 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 ALI. <br />WORKERS COMPENSATION LAWS, <br />MI ANCE NOTICE REQUIRED FOR INS ECTION - PLEASE CALL (209) 95;3-716697 <br />SIGNED TITLE� DATE / <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection B) <br />COMMENTS o <br />r0.4,,:, <br />L i <br />Employee ID# <br />Well Permit <br />PE SC <br />Codes Info <br />Received <br />B <br />CStqA <br />as <br />ount <br />Remitted <br />Date <br />Pt rmi U <br />Service Request # <br />Invoice # <br />Well ID# <br />cGl&O— <br />7 <br />�b l� <br />0-'011 p <br />�RW79NZ <br />WIU03t��o0 <br />a s 50 <br />443 7 t <br />7 C,' a <br />q 1:7-111 V <br />S o0 5 13 H ___17 <br />Wpoo3q_-�te3 <br />'fQ7 <br />way <br />iq 2v to <br />L Ko0-7r $ 2 <br />000,314 5Uu l <br />'HD 43.06 <br />4/30112 <br />WELL/PUMP PERMIT <br />