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WELL/PUMP PERMIT <br /> SAN JOAQOEN CouNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIITy7 CALL 2 09 953-7697 FOR INSPECTIONS �EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS � • © S �•� ClTyRIp <br /> CROSS STREET C:.L •,�/- tt 11 AP 4(3 ^[lam v PARCEL StZELAND Use APPLICATEON# <br /> OWNER NAME / • + N PHONE l <br /> r ll <br /> OWNER ADDRESS A II CtTYISTATEMP <br /> CONTRACTOR f/"" 13 S ` ` P�Hy/OyN}E/y/��+Y 4 <br /> CONTRACTOR ADDRESSf`'" ■ CITYISTAT.P W <br /> SuscowrRACTOR GIS PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEMP <br /> LICENSE W&-57 D C-6i L D-09 C Other NUMSE�38s ExPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: C0ordlnat0S X Y Township_ Range Section <br /> INTENDED USE DomestidRrlvate D ImgatiordAgricultural (7 Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> D Public Water System <br /> If diRerort from Owner r ama ane or ne u er <br /> TYPE OF WQRK w Well ❑Replacement Well -C well AlterationilMod1fication !I Other <br /> RNbo�nps <br /> ❑Monitoring Wells) #of wells C1 Soil 8oring(s) x of borings -i Geotechnical <br /> �❑✓Out-Of-Service Well El Out-Of-Service Well Renewal -1 Crass-Connection Repair <br /> >KfJew Pum ❑Pump Replacement ❑ Pume Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> I <br /> Drilling Method><Aud tary ❑Air Rotary C Auger 0 Cable Tool ❑Push Pant IJ Other <br /> Proposed Well Depth ~ O�) R Excavation /2— in diameter ❑Open Bottom Gravel PacwGravel Size_in diameter <br /> L Conduct Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter . In Thid../Gauge/ASTM Sched1—a0 D Steel Plastic D Stainleo S C Other �J <br /> Grout Seal Depth 1W It a Neat Cement(941b bag+5-40 gal water) and Cement ©e sack mixf7 gal water ` <br /> Bentonite(20%solids) ❑Other C <br /> Grout Placement Method0trPumped D Free Fall C Other - ❑Retardant/Accelerator(name) <br /> ih <br /> PIEDE$TAL installed By PdZriller C Pump ContractD G Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length It Thick in ❑Christy Box D Stove Pipe <br /> PUMP lf.Submersole(i Turbine L Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES; STATE LAWS, AND RULES ANIS 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 /> M H� OUIRP�VpAr�NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209),953-7697 <br /> SIGNED '?� ✓ •'^� TITLE r JI' AJI�t DATE Lla— <br /> L) <br /> / — <br /> IfAlt <br /> {V) V J <br /> E4c, 1,14 <br /> C <br /> � .+ --TJ-E-P'A-R-T-M1E N T"U S EFO N t:Y—' <br /> Application Accepted By Date O Area Employee rD# <br /> Grout inspection B Data /'� G� [ISPECIAL WBII Permit I <br /> Pump inspection By Data ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS 6-1� J It—2 <br /> PS SC Received Chs Amount DatePertni>! Invoice M Well 100 <br /> Codes Info B h Remitted Service Request N' <br /> 1,C-0 0 141 o RD vo3 ?6V <br /> 0 603198 <br />