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WELUPUMP PERMIT ��� <br /> SAN JOAQUIN COUNTY ENviRoNmENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205$232 -(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> c1 <br /> Joe ADDRESS J ctTY/ZIP_ <br /> S-�-e w <br /> CRoss STREETJ <br /> •-•�ac-K J nn P APN -003 PARCEL S=21F /_I-4ND USE APPLICATION <br /> OWNER NAME Q (.L i-n I PHONEr 2a 7/ =��� <br /> OWNER ADDRESS /s CITY/STATE21Pj I n U <br /> CONTRACTOR MOTOR WORKS lF"04 209-466-9Fi75 <br /> CONWRACTORADDREss 646 S. California Street CITYISTATEMP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEMP <br /> LICENSE . 0 C-57 9 C-61 O D-09 ❑ Other NUMBER 2247.7-8 EXPIRATION DATE 08/1A <br /> GEOGRAPHICAL INFOIRMATION: Cooidinates X Y Township Range Section <br /> INTIENOED USE 0 Domestic/PrivateJ 'Inigation/Agricultural 0 Industrial O Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System n <br /> H different from Owner. ame Name or <br /> Mono Nunfow TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteratlon/Modification 0 Other <br /> 0 Monitoring Wells) #of wells 0 Soil Borings) x*11110 0 Geotechnical u <br /> lt <br /> 0 Out-Of-Service Well pair .7""'" a �D� <br /> OOut-Of-Service Well Renewal DCross-Connection Repair❑ New Pump 0 Pump Replacement )(Pump Repair 0 Raise Well Casing 8AN JOq <br /> WELL CONSTRUCTION RO <br /> NT <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool ❑ Push Point ❑ Other liEA0 OE ARTAAlz <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom D Gravel Pack/Gravel Size In diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth it <br /> Weil Casing Diameter_ In Thickness/Gauge/ASTM Schad 0 Steel O Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/6-10 gal water) ❑Sand Cement sack m1xf7 gal water <br /> 0 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method 0 Pumped 0 Free Fall O Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> 0 Submersible Turbine 0 Other HP Pump Set ft Standing Water Level 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 /> -� "Af11NINl�I{494-IDIB, DVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED i ''fes TITLE CEO DATE <br /> Aproximately 5,100 It <br /> from Hwy 4 <br /> x.,w. 4 s ,+•. . <br /> Z�; t�PARTMt=NT U E ONLY y <br /> Application Accepted By V� Date �r�' Area Employee ID# <br /> P Y� <br /> Grout Inspection By 4z Date SPECIAL Well Permit <br /> Pump Inspecdon By r a Date S c. WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check1W Amount Permit/ <br /> Codes Info Dates Request# Invoice# Well 10# <br /> W <br /> OO ZA <br /> EMD 43-06 <br /> 8104M WELL/PUMP PERMIT <br />