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r-) WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DL—ARTMENT 600 EAST MAIN,..BEET-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 2019 953-76697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS _f rP Z � G P(J% F�/�, CETYIZ[P �C�CL�IvW �I, 52 3j"' M <br /> ..rr v <br /> CROSS STREET N. V 1G �,p. APN dS3 r� O S PARCEL SIZE LAND USE APPLICATION# m <br /> AA � <br /> OWNER NAME ��N IY f.(N6 �T PHONE <br /> OWNER ADDRESS CETYISTA-ruzIP &0CW Pu4W o ,iT5 y <br /> CONTRACTOR N�QIG �./`4''N/1 SO�/�"l�T��J Syd4- � �/�/C- / P^HONE_ - • <br /> CONTRACTOR ADDRESS /�Z �/��GI� / I[�I�` (/Y� ♦ CITYISTATEIZIP [lIiCJI 240 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE Ci-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER /Q40 I EXPIRATION DATE —0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic(Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring . oil Sampling/Characterization w <br /> ❑ Public Water System <br /> If different From Owner; Water System Name Name or Phone Number <br /> TYPE OF WORK' ❑ New Well ❑ Replacement Well D Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 1,r'Geotechnical Z: #of borings <br /> "❑ put-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> D New Pump ❑ Pump Replacement D Pump Repair ❑ Raise Well Casing <br />! WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 10--15 ft Excavation �in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched LiSteel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft D Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other SO/ C4 JZ//Q 65 _ <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <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 i <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 21 1MI MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> �j� �^ / O9 <br /> SIGNED TITLE ✓moi � GTL/(,]IC DATE <br /> a <br /> rantlt Ftl c Bran,r Rd Orandt rte <br /> r7h 4t ftd 1?0rttl;fY <br /> TW; � <br /> � € Gt <br /> ' <br /> r <br /> m I <br /> i <br /> .2 <br /> EC .IV,�� <br /> i <br /> r <br /> F" = ctrr Rd r SAN.JO � <br /> M,rRo �U <br /> - s <br /> N <br /> n, <br /> ��D P�7RQE <br /> N7 <br /> .77 <br /> — — - <br /> DEPA TME,NT U E N L Y .A <br /> t <br /> Application AcceptedTLW— Date 2 �� Area Employee ID#7TW <br /> Grout Inspection By Date © SPECIAL Well Permit / <br /> Pump Inspectio Date ❑ WAIVER Received. <br /> Soil Boring Insp tion By Date /a7 �� Constructed Well Depth ft. <br /> COMMENTS <br /> PE SC Received Che Amount Permitl <br /> Codes Info B Date Invoice# Well ID#Cash Remitted Service Request# <br /> EHD 4MIS WELL/PUMP PERMIT <br /> 8104/08 <br />