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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA LTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIr CALL(209)953-7697 FOR INSPECTIONS _ EXPIRES 11 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITYZ � <br /> P �iZ I D <br /> Cross STREET APN_ IA I /I ZS PARCF136E I')&5 LAND UBE APPLIOATIONtl G -Yly'1 2 S <br /> OWNER NAME ,y^� 1fix, //�� [�PPHHO�NE -��/1-J ✓ 1I J y <br /> + 05ICOWNER ADDRESS O V1V`e_ �t � CITY/STATE/ZIP 2It1 Novi r1+ 052-Ir- <br /> CONTRACTOR <br /> ONTRACTOR //JJ '' � ,/V!V.�(YMC 1&y-/L�S4 AI ' C- PHONE F'I.VI'gq I 3 LSI O <br /> CONTRACTOR ADDRESSL�-Wi,t A/) XLl1� CITYISTATE21P <br /> SUBCONTRACTOR PHONE <br /> SUBCOHTR ACTORA DRESS I\jCIrYISTITEmp <br /> LICENSE C-57 r 1 C-67 I0.09 I Other NUMBER E%PIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section <br /> rINTENDEO UBE DomestiUPrivale O IrdgationtAgricuhuml U Industrial iJ Water Quality Monitoring n Soil Samplirl ICharacler¢ation <br /> Pubiic Water System <br /> —:I It tliaereM lmm Omer: wataruo . e um <br /> TME OF WORK 21 New Well I I Replacement Well N Well Alteration/Modiliostion 0 Other <br /> Monitoring Well(s) SOfwells OSON Borings) xofso , 7. Geotechnical ror eR.vNs <br /> Out-Of-Service Well I'.Out-Of-Seriice Well Renswat O Cross-Connection Repair <br /> ew pump r';pum�Replacement ❑ Pump Repair G Raise Well Casing <br /> WALL CONSTRUCTION <br /> Drilling Method I I Mud Rotary n Air Rotary Auger Cable Tool I Push Point ❑ Other <br /> Proposed Well Depth it Excavation in diameter rl Open Bottom O.Grovel PaWGravel Size in diameter <br /> Conductor Casing In diameter / Conductor Casing Depth it <br /> Well Casing Diameter_in ThicknesslGauge/ASTM Schetl 1.1 Steel I l Plastic ,'.Stainless Steel Other <br /> Grout Seat Depth it I Neat Cement(94 16 beg/5-10 of water) n Sand Cement sack mix/7 gal water <br /> c Bentonite(20%solids) Other <br /> Grout Placement Method ❑Pumped :'-Free Fall J Other 0. Retardant/Accelerator(name) <br /> 1-PEDESTAL Installed By Driller Pump Contractor n Other <br /> Concrete Pedestal Dimensions:Width R Length ft Thick in o ChristyBox it Stove Pipe <br /> f P ubmersible"'.Turbine Other HP PumD Set it Standing Water Level <br /> 1 HEREBY CERTIFY THAT 1 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. 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 COMPENS ION LAWS. <br /> MINI t3 124 �tl' A t E NOTICE REQUIRED FO NSP C I -PLE E CALL(209)95 -769 <br /> SIGNED TITLE DATE <br /> - - <br /> 211 <br /> W. <br /> 1 A U <br /> A p MM <br /> i <br /> vie <br /> 1i- - <br /> DEPARTMENT USE ONLY �� �r� <br /> Application Accepted By N �1 Date 3f Area Employee l0#fAdf/^w <br /> Grout Inspection BBy. r Data CI SPECIAL Well Permit <br /> Pump Inspection Data ❑ WAIVER Received <br /> Soil Bonng Inspection Syr Oats Constructed Well Depth it <br /> COMMENTS - <br /> li 1�/K/.t�. /��_�''�"C� 7 =✓fly <br /> I PE SC Received LyBgtJla✓ Amount pe—'V <br /> Data Invoice# Well et11De <br /> Codes Info a Cash Remitted _ _ Service Request R <br /> kapo osv l X88 fS3 <br />