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i33;-1 (c t <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> p t t� I <br /> JOB ADDRESS I", SO N. `'�L—L�l�r ]A( r_G�t.W/71�,P,�� <br /> CITY CIY^r CLf1G �T��n Sgt <br /> CROSS STREET ulOOc��r1 U�'R C C1L,j APN�L a, (101`4)PARCEL SIZEV LX LAND USE APPLICATION# S <br /> OWNER NAME � "�^-' PHONE 7 q <br /> OWNERADDRESS --1--t3t6 72odL✓t I.ay—ev4 CCITY/STATE/ZIP�` <br /> CONTRACTOR e.' — { <br /> `✓t�n s;l k2l 22 & ;7 288 PHONE 2Q S--� �`'7 4,,,,- <br /> CONTRACTOR ADDRESS 2,-n I ` [�"\,CY`� (..iYF�M CITY/STATE/ZIP C .ICT'6�17�,r�S'!7 <br /> SUBCONTRACTOR -�J '{l1, ✓Lr r-�^ PHONE 2, l_ 5.� ot7 <br /> SUBCONTRACTOR ADDRESS : �O(rte-'j j C 1,4C (�(`1,�[�2L1.fC� CITY/ST <br /> �A <br /> 7,TE/ZIP <br /> LICENSE C-57 C-61 D-09 Other t� ` NUMBER �"1 n EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDEDUSE Domestic/Private _ Irrigation/Agricultural Industrial Water Quality Monitoring KSoil Sampling/Characterization <br /> Public Water System <br /> 11 different from 0v ar Wait.,System Name on ec Name or one um er <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) <br /> a or Comigs Geotechnical—�—x awe' <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement 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 If Excavation &"' in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b baglSfO gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) 7,0ther C zh jam/y '117 of <br /> ,Grout Placement Method Pumped .. Free Fall Other .i Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedesta)Dimensions:Width It Length It Thick in - Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level it <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 /> Q -JNjNIMU 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED ty-D-�---�- V �'y�' �- TITLE Pn•j e-c - Lhr�l�""•"-'Y DATE <br /> UtGO <br /> NN <br /> L <br /> N tMIH ENT <br /> E i, <br /> lc-'JS- c <br /> DEPARTMENT USE 0N11 v <br /> Application Accepted By Date ,iz. Area �SPECIAL <br /> Employee Ill#��Grout Inspection By Date Well Permit <br /> Pump Inspection Date / WAIVER Received <br /> Soil Boring Inspection By Date S! 7 a//4 Constructed Well Depth ft <br /> PE Sc Received (' Check#/ Amount Date PermiU Invoice# Well ID# <br /> Codes Info B -ash Remitted Service Re uest# <br /> ISO 2,( 135.3 03 3ti RC�Dr�]D <br /> EHD 43-M WELL/PUMP PERMIT <br /> 8104M <br />