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�•l� :,Ui,� r� r_l1 <br /> ,U 3 <br /> J <br /> WELL/PUMP PERMIT ! J <br /> ,;_iIC� �C � <br /> SAN JoAclum Coutm EwRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STocKTON CA 95205.6232 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 9 YEAR FROM DATE ISSUED <br /> b q arc, w CITY/DP- S�o �n 4 95� l5 <br /> JOB ADDRESS n <br /> I h �1CL rAPN -D /' 1 Q / 7 <br /> CROSS STREET PARCEL S¢6ZYl'LANo USE APPLICATION# Q ;� <br /> OWNER NAME : Lt--irte7 7 1 /HAM Y' HONE 2-69- 4,67 <br /> OWNER ADDRESS �A A E t/1�F (�/�,� �g CITY/STATErLIP de r 61A gZS-L7 <br /> CONTRACTORAgmArpligiF MOTOR WORKS 9'ifiL 209-466-9F+25 <br /> CONTRACTORADDRESs 646 S. California Street CITY/STATEMP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRMS CITY/STATE21P <br /> LICENSE - D C-57 9 C-61 ❑ D-09 Cl Other NUMBER 7247.t$ EXPIRATION DATE 08/1� <br /> GEOGRAPHICAL INFORMATION: COOFdinates X Y Township Range Sectlon <br /> INTENDED USE 0 DomestiGPrivate ACirrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different 6om Owner r ZSPM Narne Conuta Name or Mono Nurnber <br /> TYPE OF Wo Rx O New Well O Replacement Well O Well Alteration/Modification O Other <br /> O Monitoring Well(s) #of wells 0 Soil Boring(s) #of boffiVa O Geotechnical °�of bortnge <br /> 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement &Pump Repair 0 Raise Well Casino <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other s <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Weil Casing Diameter_in Thickness/Gauge/ASTM Schad 0 Steel 0 Plastic 0 Stainless Steel O Other <br /> Grout Seal Depth ft 0 Neat Cement(94 lb bagl&10 gal water) O Sand Cement sack mlxl7 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other O 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 /> PUMP ❑ 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.1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 9 -MMgM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ) <br /> SIGNED <br /> TITLE CEO _- _ DATE <br /> � r <br /> f i <br /> - ...-►--�","" ,. _• . ., '. ��. fin.. �. , <br /> EI VEp <br /> A <br /> sol apiin par aaS Ty <br /> VI <br /> �_ •� • r <br /> P TMENT USE LY <br /> Application <br /> _0;0 Oon Accepted By Date <br /> Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By '?Q�� Date v�� , � . WAIVER Receive4- <br /> Soil Boring Inspection By Date Constructed Well Depth :* ft <br /> COMMENTS <br /> PE SC Recelved heekiRf Amount Permit/ <br /> Codes Info B as Remitted Date Service oast# Invoice# efI lD# <br /> EMD 43-06 <br /> 610 M WELL!PUMPPERMIT <br />