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i WELL/PUMP PERMIT ` <br /> 601 EAST MAIN STREET <br /> D -STOCKTON CA 95202 -(209)468-3420 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> NON-REFUNDAB`LE�fPERMIT� (,/�J CALL(2209^953-7697 FOR INSPECTIONS pEXPIRES 1 YEAR FROM DATE ISSUED N <br /> / Z 1 :3 s ■�� Mr~ P✓ - CITY/LP <br /> JOB ADDRESS � Q <br /> CROSS STREET _APN � � f 7 _PARCEL SIZE�j LAND USE APPLICATION# <br /> OWNER NAME �S`U �Z- � y -LY, - PHONE 2.l a-7 60-lc <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> J <br /> PHONE 334. 11725' <br /> CONTRACTOR <br /> CITY/STATE/ZIP C11i;1 Y "/ f <br /> CONTRACTOR ADDRESS /JL - V <br /> SUBCONTRACTOR 12 <br /> I`3,( Gam" r PHONE <br /> SUBCONTRACTOR ADDRESS .. - _ C_I-TYI•STTAATTEIIZZIIP' - <br /> A 1 <br /> LICENSE ,Y3�:57 C C-61 ❑ D-09 D Qthef ' <br /> HUMBER £XpIRAT1DN DATE—C- <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township__ Range _---7] <br /> Section <br /> INTENDED USE Domestic/Private 0 Irrigation/Agricultural n Industrial C Water Quality Monitoring 0 Soil Sampling/Characterization <br /> Public Water System er sem ame a ame or lie um r <br /> I If different horn Owner Y <br /> TYPE OF WORN Jew Well I I Replacement Well D Well Alteration/Modification Other 0 o Eonnps <br /> LMonitoring Well(s) #of wells 0 tt of rings Soil Boring(s) 0 Geotechnical <br /> n P t-Of-Service Well D Out-Of-Service Well Renewal C Cross-Connection Repair <br /> ew Pump 0 Pump Replacement ❑Pump Repel <br /> WELL CONSTRUCTION y �� <br /> Drilling Method>Mud Rotary Air Rotary L Auger t�O Cable Tool push Point C Other <br /> Proposed Well Depth_ft n Excavation Ll ..in diameter I i Open Bottom >4ravel Pack/Gravel SizeIn diameter <br /> n Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-6—in Thickness/Gauge/ASTM Sched'L-1317n Steel 14TPlastc D Stainless Steel 0 Other Vi <br /> Grout Seal Depth ft 0 Neat Cement(94 Ib bagiSlO gal water) Sand Cement-- _sack mixT7 gal water <br /> Bentonite(20%solids) 7 Other <br /> Grout Placement Method/-Pumped 0 Free Fall O Other n Retardant I Accelerator(name) m <br /> IPEDESTAL installed By riller a Pump Contractor i i Other <br /> I I Concrete Pedestal Dimensions:Width---L, L Length ft Thick In 0 Christy Box C Stove Pipe �p <br /> PUMP /'Submersible❑Turbine -- Other HP Pump Set ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> _CURRENT <br /> COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS. <br /> AND ACTIVE WITH THE CALIFORNIA__ CONTRACTORS STATE LICENSE BOARD AND THAT I�rN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS.'--- ---- —�' ^� _^ <br /> INIMUM 24 HOUR ADVANCE NOTICES REQUIRED FOR INSPECTIONS <br /> SIGNED <br /> TITLECC/���"' DATE <br /> O - <br /> I ! - <br /> I f <br /> / 4 <br /> - G <br /> S - <br /> - 5 <br /> S <br /> 4 V <br /> I <br /> IR N - U <br /> ) <br /> PR <br /> �D-E-P'A-RT M-ETI-T�U-$-E-`OrTI`C•_� <br /> t <br /> Application Accepted By-f T Date 09 Area — _ Employee ID# 59Cf� <br /> " Grout Inspectio / � Date L SPECIAL Well Permit <br /> / <br /> Pump Inspection y Date 7 ❑ WAIVER Received <br /> ° <br /> Soil Boring Inspection By Date Constructed W#ll Depth ft <br /> COMMENTS <br /> I <br /> PE SC Received Check Amount pate Permit/ Invoice# Well ID# <br /> 1 Codes Inco B ash Remitted Service Re u@st# <br /> 43(P& (rg-0 L.& 904q � -7/0og 005 49 Pon,,27-3'7 <br /> L.2 osso Sv tw 0o�85oz ,. <br /> I <br />