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UC `� 1 l� �r.rkwl SL,.. Y) b"��' 4(� of 3't/ <br /> 3 WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT ti, CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> /j/r q � N <br /> d b I Q (� q �� ) m <br /> JOB ADDRESS '" �_` CITY/ZIP `t/CT 3 7 _. D <br /> CROSS STREET C-�'J { APN `1 l b -_PARCEL SIZE/'� LAND USE APPLICATION A n <br /> N <br /> OWNER NAME \Cw-lti-(„ 1h IVk HONE !QO 177 (�/\4`.� S N <br /> OWNER ADDRESS " CrTY/STATE1ZIP �+ 1� <br /> CONTRACTORJJ��Ctn P ME -J ✓u <br /> CONTRACTOR AUDRESSPy sw ��'\�' �''\ C.�9`1�yY Cm/STATE/ZtP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CFry//SSTAATTEIZPP_✓ \/ ( <br /> LICENSE 17.57 1)C-61 r)D-09 [)Other NUMBER 'v E%PIRATION DATEv1e+`T <br /> i, ,4O q <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE - Domestic/Private 0 Irrigation/Agricultural rJ Industrial ;l Water Quality Monitoring U Soil Sampling/Characterization <br /> f f Public Water System _ <br /> If difierem from Owner. Water System Name IeU Name or Phone Number <br /> TYPE OF WORK D New Well 7*Replacement Well 0 Well Alteration/Modification ❑Other <br /> �. <br /> 0 Monitoring Well(s) a of wells 0 Soil Boring(s) a of bOef Vs 1_2 Geotechnical a of befo <br /> t„r1Ya�u( OOut-Ol-Service Well U Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> C'Pump Replacement 0 Pump Repair r Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)C'Mud Rotary 0 Air Rotary C Auger L U Rible Tool u Push Point 0 Other <br /> Proposed Well Depth 490 it Excavation k 7�14 In diameter ❑Open Bottom l'Gravel Pack/Gravel Size in diameter <br /> U Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter�in�7�,�c ss/Gauge/ASTM Sched _ U Steel JdRlastic C Stainless Steel 0 Other_ <br /> Grout Seal Dept� 1Y�.IF', Neat Cement(941b bag/5•10 gal water) J>!Sarxi Cement �U t{ sack mixl7 gal water <br /> T iy D 4+Jf , <br /> 3k _"�r ❑Bentonite(20%solids) .l Other <br /> Grout Placement Method IS Pumped I:!Free Fall r:Other [I Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 DrillerPump Contractor W Other bL JCUt - <br /> ^.Concrete Pedestal,-Dimensions:Width it Length it Thick In 'I Christy Box M Stove Pipe <br /> PUNP 'v. " :)626trbmersibler;Turbine I;Other HP Pump Sel It 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 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 /> MUM 2I H0jJR ADVANCE NOTICE REQUIRED FOR— <br /> INS/PAEC')TIONS-PLEASE CALL 9))[953-7697!_ <br /> SI'Z TR}R' `Y ♦� DATE 9 <br /> .��, <br /> r�- <br /> & � '0. <br /> . <br /> 1 t (_r <br /> l` •y �'—�r..._�el�...+�._..._ _ I SME <br /> l DEPARTMENT USE ONLY <br /> ADPliyat(in F,aceptod By <br /> __ Date A 5 L� _ Area_0� ri E:sp!oycc:Ds <br /> Grout Inspection By " Date L SPECIAL Well Permit <br /> Pump Inspection. Date WAIVER Received <br /> Soil Baring Inspection¢y Date Constructed Well Depth fl <br /> COMMENTS j��W Lot o k <br /> , r� t <br /> PE SC Recelve:+T Checks/ Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Request is Invoice s <br /> ►�� L( � c-:,p G G ti% <br /> L � \ <br /> G <br /> E14043-06 ZLY (. Vl' 57W WELL <br /> .c P <br />