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.• TrM s cud to-x5-1b M— <br /> • WELUPUMP PERMIT <br /> SAN JOAQUIN COUN-1Y ENVIRONMENTAL HEALTH DEPARTMENT 1868 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 /> JOB ADDRESS � 1"� CITY21P c\ � L/I7 I \ (/'/ m <br /> CROSS STREET -G f APN / PARCEL SIZE V LAND USE APPLICATIONS#Q <br /> OWNER NAME 24 1Z AP AP PHONE ��2���+ �+ 3 N <br /> OWNER ADDRESS O r/���p� ��04 CITY/STATE/ZIP- <br /> CONTRACTOR <br /> CONTRACTOR le'< 49A&SS G &/'4'-r1" PHONE ��+�—�t �✓ <br /> CONTRACTOR ADDRESSL? CITY/STATE/ZIP ` — co✓1G �V I�� 1 <br /> SUBCONTRACTOR 'W R/ `^���✓ PHONE K+ --L7d7 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ,LC-57 i C-61 F, D-09 OtherNUMBER o 7"a 3?,r /EXPIRATION DATE a`/;7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE °<•Domestic/Private Irrigation/Agricultural I Industrial i Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System ameontadtame or Phone Number <br /> TYPE OF WORK >New Well XReplacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair RECEIVER <br /> ew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTIONuc, 1 5 201E <br /> Drilling Method +-Mud Rotary 1 1 Air Rotary i_ Auger i Cable Tool i Push Point Other SAN IGh� /U <br /> Proposed Well Depth r Excavation Z in diameter I Open Bottom Gravel Pack/Gravel NNS jFj r <br /> I i Conductor Casing in diameter / Conductor Casing Depth ft VAk1_MEN7 <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched'�V liL-Z-( i Steel XPlastic i i Stainless Steel 11 Other <br /> Grout Seal Depth_ft ❑ Neat Cement(94 Ib bag/5-10 gal water) [)"Gand Cement /rC)" sack mix/7 gal water <br /> i 1 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method>t Pumped I i Free Fall Other i Retardant/Accelerator(name) <br /> PEDESTAL Installed By driller Pump Contractor Other <br /> Concrete Pedestal 'Dimensions:Width�ft Length ft Thick in Christy Box ❑ Stove Pipe <br /> PUMP .,Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> i <br /> I HEPEBY 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 /> MINI= HOO ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209)953-7697) <br /> SIGNED TITLE V&1Aeh­ DATE <br /> ac <br /> _ i <br /> L I01 <br /> rpm -401 <br /> it <br /> 11,T71 <br /> i <br /> _ I 1 <br /> I <br /> D PARTMENT USE ONLY <br /> D, <br /> Application Accepte y Date Area Employee ID#�D <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 11 1'� CI WAIVER Received <br /> Soil Boring Inspection By Date_�t o2 Constructed Well Depth ft <br /> COMMENTS L1C�STI/L�cJ W5U,K��/A A6 (/U Rkcr--i' m C� U c = <br /> PE SC Received Check# Amount pate Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> �.U° i� Z51r'e sr-' -7 o _ \0003V911 <br /> S'b . 0.O° ZS S 0 q 003 2' �v <br /> o U IS KOv -7Yv fftj <br /> 4/30EHD 43-06 �0��� I f� ��nfYll„/I��1 WELL/PUMP PERMIT <br />