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1 <br /> ' WELL/PUMP PERMIT S E ` <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 -(209)469-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTION.; EXPIRES 1 YEAR FROM DATE ISSUED <br /> T <br /> 2agj gjLnSSo]�1 �-0 <br /> JOB ADDRES �� YJZ[P y <br /> CROSS STREET / 1L°'r~'� APN tClf <br /> PARCEL Si7E LAND USE APPLICATION# A� <br /> OWNERNAME `� r+0 Uw.ry'—' PlIONE�( �7,r <br /> OWNERAOORESS ]�I1iVLJL� ' �'� r,`1`'L" �C' CITY/STAT ST "� `A <br /> CONTRACTOR W — k�O�,ALLL��/t GY)4� ce IAMEr, CPRONE ��Lr q2Z <br /> CONTRACTOR ADDRESS 31110 W ' , c iC"r — A 4 CiTv1SYATPIZJP 7�ck�t4/`l� I)S2-11 L� <br /> BURCONTRALTOA WET GmAtST '�+xi `— 'tom-n�� _— PILON, /��� <br /> SUBCONTRACTOR ADDRESS T 0. GOK 1�i -___ C1.TY1STAA'TIUZIP � � c''`` <br /> LtCSNSE C-57 QC-61 13D-D9 (2 Other NUOtaER t /"7(0 I ExP1RATIDNDATE ) <br /> CEGGRAPHICALINFORMATLON. Coordinates X Y Township_ Range Section <br /> 1NTT:NOED USE ❑Domeslic/Private O trrigationlAgricultural O Industrial O Water Quality MOnildring Soil Ssmpling/Chsracterirafio <br /> Cl Public Water System <br /> .. ... <br /> r! Ifdiff.—t fmm OO�rr+ atcr SPAM Nernt Coawt Na or Plione o - <br /> Cl New Well 13 Rcplecetncnt Well O Well Altcration/Madificaoon O Othcr <br /> Cl Monitoring Wcll(s) #ofwclls O Sail Boiiag(s) aotbm ngs )(Gwwchnica _a ofbonogs <br /> O Out-Of-Service Well O Out-Of-Service Well Renewal O Crass-Connection Repair <br /> O New Pump O Pump Replacement O Pum R air - <br /> WELL CONSTRUCHO _t1 <br /> Drilling Method O Mud ROLM 13 Air Rotary Auger O Cable Tool ❑Push Point O OtherhT <br /> Proposed Well Depth 50 R E.xcovalion ! . in diameter O Open Bottom O Grave;Pack/Gravel Size in diameter '1 <br /> O Conductor Casing in diameter I Conductor Casing Depth R <br /> Well Casing Diameter—in Thiclmess/GaugeASTM Sched O Steel O Plastic O Stainless Steel O Other <br /> Grout Seal Depth( fl (Neat Cement{94 Ib bag/5-10 gol w fr ) O Saud Cement sack mir/7 go]water <br /> O Bentonite(20%solids) O Manufacturer Spec%solids % Name O Specs on File O Specs Submitted - <br /> Creut Placement Method O Pumped O FreeFall Ocher:TVJP4LS 0 Retardant I Accelerator(name) <br /> PEDESTAL Installed By O Driller O Pump Contractor O Other <br /> O Concrele Pedestal Dimensions:Width ft Length fl Thick in O Christy Boa O Stove Pipe <br /> D <br /> PUMP O Submersible [3 Turbine O Other HP Pump Set R Standing Water Level It <br /> I HEREBY CERTIFY THAT I HAVE PRE PAR�D THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN V� <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS r9 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL 3 <br /> WORKERS COMPENSATION LAWS <br /> MUM 24 HOUR ADVANCE NOTICE REQUIRED <br /> /FOR <br /> �INSPECTIONS <br /> ITt 4 <br /> SIGNED TLE S 1 t'C� L�c+`-' DATE LA <br /> ora <br /> O g <br /> A <br /> � r s <br /> O SAN <br /> 'F . :_ ENVi <br /> c n ,r,. s k D PAIVIEpr <br /> seas sR <br /> HFd VER <br /> DEPARTMENT U E ONLY - <br /> Application Accepted By PateZ [1 Arca Employee[D#s3L+�� �c'J <br /> Grout Inspection By Daic 0 SPECIAL Well Permit <br /> Pump Inspection By Data 13 WAIVER Received <br /> Constructed Wyll Depth It <br /> COMMENTS <br /> / ly <br /> P£ SC Received Cbec Amount Dale Permluin #— Welkl <br /> Codes ]Oro B ash Remitted S"r eRequest# <br /> EHD A3-02-W wCLL PUMP PERM,rr <br /> IRTRaaS <br /> r) <br />