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WELLIPUMP PERMIT <br /> DEPARTMENT <br /> JOAQUIN COUNTY ENVIRONMENTAL HEALTH 60o EAST MAIN STREET-STOCKTON CA 95202 -(209)468.3420 <br /> AN <br /> NON-REF NDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED FOR <br /> iz 3S £-13�s m t <br /> JOB ADDRESS tri �� � CITY/ZIP <br /> Gv <br /> CROSS STREET APN f r - «O^f 9 PARCEL S�E��ULAND USE APPLICATION# A i <br /> OWNER NAMEPHONE <br /> OWNER ADDRESS O l /` CITY/STATE/ZIP /-7 I <br /> [A G/` PHONE t�.7T -f. L I.5' j <br /> CONTRACTOR /,/! /y/� <br /> CONTRACTOR ADD RESS CITY/STATE/ZIP vv�y n` , <br /> SUBCONTRACTOR I`lV ,`'t t G �r - PHONE <br /> ' <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP- r7 <br /> LICENSE �. -57 L.1 C-61 ❑D-09 ❑ Other NUMBEl ExPIRATIDN DATE 1 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range -Section <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> Public Water System ---C-r3a�c 1Pame or orre um er <br /> H dlfferert from Owner. er ys em ame <br /> TYPE OF WORK >4ew Well ❑Replacement Welt ❑Well Alteration/Modification ,.f],Other #of lI ❑Monitoring Well(s) #of wells Li Soil Bonng(s) :1 Geotechnical <br /> ❑put-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Pum Replacement ❑Pump Repair <br /> rWell <br /> CONSTRUCTION l <br /> thcd,C MUd Rotary ❑Air Rotary ❑Auger ❑Cable Tool -i Push Point ❑ Other <br /> I Well Depth _ft ' Excavation�,L,_in diameter ❑Open Bottom ravel Pack/Gravel Size in diameter <br /> n Conductor Casing in diameter / Conductor Casing Depth ft <br /> ing Diameter in Thickness/Gauge/ASTM Sched`L� ❑Steel Plastic ❑Stainless Steel a Other �, <br /> / Grout Seal Depth at�—ft ❑Neat Cement(941b bag/5-10 gal water) Sand Cement_ _ sack•mixl7 gal water <br /> } F Bentonite(20%solids), LI Other m <br /> Grout Placement Method7,wumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ;. eller ❑Pump Contractor C Other <br /> Concrete Pedestal Dimensions:Width'_ft Length ft Thick in _-Christy Box 7 Stove Pipe V� <br /> I <br /> PUMP ,�'�'�SubmersiWe❑Turbine ❑Other HP Pump Set ft Standing Water Level It <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> l <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS It' <br /> I CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL IAZ <br /> WORKERS COMPENSATION LAWS. f <br /> MUM 24 HOUR ADVANCE NOTICfEq[REQUIRED FOR INSPECTIONS _L 7 <br /> SIGNED INI <br /> TITLE v'' � DATE <br /> I <br /> - <br /> t <br /> G <br /> - <br /> I <br /> 4 <br /> Z - <br /> IR Iy G U <br /> '-- D E'P SRTME N'T�tl �0`N'L <br /> Application Accepted By 'Date d� Area - Employee ID# '-94 4 4-' <br /> - Grout Inspectio l 1) Date .� C SPECIAL Well Permit <br /> Pump Inspection .l-� / � Date J WAIVER Received <br /> Soil Boring Inspection By _ Date Constructed W,gil Depth ft <br /> i COMMENTS <br /> PE SC Received Check Amount Date Perm <br /> iU Invoice# Well ID# <br /> l Codes Info B ash Remitted Service Re uest# <br /> �3 W, (k-0c,� 9 D -1 9/o g �� 8 Paa�7.�7 <br /> r�-Wo ©S'u s�.I� w po=285oz <br />