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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STocK7ow CA 952066232 -(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADORE83 8 3 3 S N 19 1 n <br /> - _ <br /> cCrtY/ZtP 952 , <br /> CROSS STREET �e l APN0 O636469CEL <br /> g <br /> PARCELSaE 57LANDU8EAPPLICATIOk# p <br /> OWNER NAME 7rori <br /> /�� ava' Q Q PHONE <br /> S / "l <br /> OWNER ADDRESS E O S� CITY/STATEMP: jj� cpgg-1— ��Uu <br /> CONTRACTOR Delta P�qi�� 'QCKTON ARMATURE A MOTOR WORKS 900209-466-9625 <br /> CONTRACTORADDRESS 646 S. California Street CnY/STATE21P Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEMP <br /> LICENSE . 0 C-57 9 C-61 00-09 O Other NUMBER .7247$ ExPtRATION DATE 08��� <br /> GEOGRAPHICAL 1NFoftMATtON: COojdlnates X Y Township Range Section <br /> INTENDED USE 0 Domestic/Private Irrigadon/Agricultural 0 Industrial O Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different It=Owner, Water Name or m <br /> TYPE OF WORK Dw <br /> 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Wells) #of wells 0 Soil Borings) a of bofitps 0 Geotechnical d of bOFkW <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Re lacement -oW'Pump Repair 0 Raise Well Casing <br /> WELL CoNmucnoN <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger O Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth ft Excavation In diameter 0 Open Bottom 0 Gravel PacldGravel Size In diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_ In Thickness/Gauge/ASTM Schad 0 Steel O Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth_ft ❑ Neat Cement(941b bagt5.10 get water) 0 Sand Cement sack mlx/7 gal water <br /> 0 Bentonite(20%solids) 0 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 It Length It Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible Turbine 0 Other HP Pump Set It 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE 1S <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT.1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> .'MINIMUA 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED " TITLE_ DATE / <br /> st <br /> 44. <br /> y ..y <br /> t7l 71 <br /> P TMENT U E 9,NLY <br /> Application Accepted By &wDate <br /> Area Employee ID#�L <br /> Grout Inspection By <br /> Data SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS .k�. C� x eA ` �A T <br /> PE SC ReceivedAmount Peery <br /> Codes Info B ash Remitted Date Serviceuest# invoice# Well 10# <br /> 3ctL4-7-75 17 �7 <br /> EHD 4108 <br /> 8104M WELL/PUMP PERMIT <br />