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t <br /> WELL/PUMP PERMIT <br /> SAN JOAGIAN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1068 EAST HAZELToN AVENUE-STOCKTON CA 95205-(209)468-5420 <br /> NON-REFUNDABLEX PER/ ? <br /> MIT( �J �` I <br /> CALL 209963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> I <br /> Joe ADDRESS � I �`I'� I`t.' <br /> C " /� CITy/ap Le �1 ' ���: <br /> CROSS STREET �t� '��:�� ) R U APN O 51- 1 L' -I pgRCEL SIZE 2LLAND USE/APPLICATION i / <br /> OWNER NAME '� St�� rl PHONE 4i C'� - C�.�Cy a <br /> OWNER ADDRESS (�T CJ CITYlSTATE21P <br /> CONTRACTOR I '7 1 J PHONE ��•�1 - 7`1 <br /> CONTRACTOR ADDREss Ci I7 C� y CITY/STATEIZIP ��'I'k I C cl Cj C. +� <br /> SUBCONTRACTOR PHONE <br /> $uscoNTRACTOR ADDRESS CITYISTATeFZIP <br /> UCENsE )�C-57 C-61 D-09 Other NUMBER J S EXPIRATION DATE -7-31-12 <br /> GEOGRAP14CAL INFORMATION: Coordinates X Y Township_ Range Secdon_ <br /> INTENDED UsE stldPhvate _Irrigation/Agricultural 7 Industrial Water Quality Monitoring _Sol SamplinglCharacterizabon <br /> Public Water System <br /> If different from Owner. w ne <br /> TYPE OF WORK New Well =Replacement Well _Well ARerstionVModification 'Other <br /> Monitoring Wells) 0 of wells =SON Boring(s) a or Wrings ::Geotechnical a of rxv npe <br /> Out-Of-Service Well - Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement _Pump Repair �i Raise Well Casing <br /> WeLL CONSTRucTIa+ <br /> Drilling Method 7-Mud Rotary Air Rotary Auger 'Cable Tool - Push Point Other <br /> Proposed Wail Depth 3 C.`15 ft Excavation In diameter Open Bottom x0ravel Pack/Gravel Size /u- In diameter <br /> 0 Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter - In Thickness/Gauge/ASTM Schad CI Zo =Steel /9,Plastic Stainless Steel Other <br /> Grout Seal Depth CC% ft -Neat Cement(94 Ib bag/5-10 gal water) Sand Cement 1 C S sack mixR gal water <br /> ._Bentonite(20%solids) _Other <br /> Grout Placement Method umped _Free Fail _,Other _Retardant f Accelerator(name) <br /> Instalied By _ rillerPump Contractor Other <br /> Concrete Pedestal-Dimensions:Width�_fl Length ft Thick in Christy Box "" Stove Pipe <br /> SuMnersible-Turbine -Other HP-�)_ Pump Set ft Standing Water Level R <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 /> MINIM 24 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- 1PLEASE CALL(209)953-7697 `p <br /> SIGNED z` �R�'a'" TITLE �l\C(r S Cti y) DATE <br /> W <br /> 1 <br /> 1 <br /> s <br /> PAY E� <br /> REC 1 <br /> Alp <br /> d <br /> SP 93 ROTI <br /> EP RTMENT U E O Y <br /> ZA <br /> Application Accepted 8 Date Area Employee IDM <br /> Grout Inspection By S C�t+�- Date / PECIAI Well PSI Mit <br /> Pump Inspection By J Data \b 2 t I "o J WAIVER Received <br /> Soil Boring Inspection By Date Constructed Wait Depth rt <br /> COMMENTS <br /> PE SC Received CheckM/ Amount Date Permit/ Invoice S Well IDM <br /> Codes Into Cash Remitted Service R est it <br /> .� Aix-- w�� ►�oa� �i <br /> -� -� <br /> '0 WiLiql< <br /> WELL/PUMP PERMIT <br />