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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202- (209)466.3420 <br /> NON-REFUNDABLE PERMIT CALL 299 953-7697 FOR INSPECTIONS EXPIRES 9 YEAR FROM DATE ISSUED <br /> JaBADDREas to <br /> CIry21P_ <br /> CROSS STREETA j <br /> APN `Z PARCEL$IZELAND USE APPLICATION# �y <br /> OWNER NAME �^ m <br /> PHON <br /> OWNER ADDRr-SS C IPr1STATE171A <br /> CONTRACTOR 16 <br /> PHOx "bF-� <br /> CONTRACTOR ADORE$$ CITYfSTATFIZIp <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS C NISTATEMP <br /> LICENSE C-57 C-r31 C 0-09 :1 Other NUMBER ExPIRATION DATE D <br /> GEOGRAPHICAL INFORMATION: GocrdinTnes X y Township Range Section <br /> INTENDEDSE Domestir�PMate C In'igationAAgricuhural q industrial C Water Quality Monitoring ❑Sol SamPing/Characterization <br /> ❑Public Water System <br /> IfditreMhpm Owner. y m artle u r <br /> IYPE OF WORK 7 NOW Well ❑Rep!aoement well C Well AlterationlModificatiom C Other <br /> Monitoring Wall(s) _A of welts C Solt Boring(s) °Qr h°"'e6 -:J Geotechnicai Eorborings <br /> ❑Out-Of-Service W I ❑Out-Of-Service Well Renewal 7 Cross-Conne con Repair <br /> U New Pump 11.PReplacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drll9ng Method r Mud Rotary U Air Rotary ❑Auger C Cable Toof ❑Push Point ❑ Oftr <br /> Proposetl Well Dept it Excavafion in diameter O Open Bottom C Gravel PackjGnevel Size <br /> El Conductor Casing in diameter 1 Conductor Casing Depth ft in diameter <br /> Well Casing Diameter-in Thickness/Gauge/ASTM Sehed C Steel r Piastic 7 Stalkless Steel ❑Outer ' <br /> Grout Seal Depth it C Neat Cement(94 lb baWS-10 gal water) ❑Sand Cement <br /> U Bentonite(20%soilds) ElOther seckmlxl7 gal wahar <br /> Grout Placement Method U Pumped III Free Fall U Other_ :1 Relartlant 1 Accelerator{name) <br /> C Concrete <br /> 1' I9lz Installed tG Drliler 3 Pump Contractor ❑ Other <br /> Pedestal Dimens[pns:Width ft Length It Thick in ❑Christy Box ❑stove Pipe <br /> &MP LbmarsibleO Turbine O Other <br /> HP <br /> JOAtZUiN COUNTY ORDINANCEPump Set it Startling Water Level ft <br /> 1 HEREBY CE THAT 1 HAVE PREPARED THIS APPLICATION AND THAT TME WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> S, STATE LAWS, AND RULES AND REGULATIONS. [ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I A l COMPLIANCE <br />'t WO COMPENSATION H WITH ALL <br /> SIGNED NI U HO R ADVANCE NOTIC EQUI D FOR INSPECTIONS <br /> TITLE DATE <br /> I <br /> R-- <br /> Id <br /> A o <br /> f <br /> DEP R MENT USE ONLY <br /> Application Accepted By <br /> Data By Grant inspection Area Employee 117# <br />� inspectionto [ <br /> SPECIAL Well Permit <br /> Pump I nspecaan By =' 6ate.. I�1 <br /> LI WAIVER Received <br /> SNI Boring Ins an By Date Constructed Well Depth <br /> COMMENTS �yj(j� R <br /> ytf p first +7 iL" fi i2r 1dE S G' _ <br /> PE SC Received Amount <br /> Cadea IDfO D ParmW <br /> Remi <br /> it, <br /> Invoice# <br /> Well ID# <br /> 3 to <br /> j ss� � ra.`' : a a53o 7i CD27zo`? <br /> EHD 43-M <br /> W2&W <br /> W RL/PUMP PERMIT <br />