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WELL/PUMP PERMT <br /> SAN JOAQUIN Courrr ENVIRONMENTAL HEALTH DgYARTMEMT 304E WEBER AVE 3'Fl.-STOCKTON CA 95202 -(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED w <br /> n Ga <br /> JOBADINUDS _ / / Cmizu, <br /> v <br /> CHOSE STREET L APN � — 166 <br /> PARCLL SILE3•/6 LAND USE APPLICATION N <br /> WN <br /> OER NAME JA r n' /r� y/7 PHONE n�. <br /> OWNERADDR 1�r D GQZP 42=4 CTTT/STARZIP OJT Cil. <br /> CONDUCTOR PHONE <br /> CONTRAUCRADDR1.55 CRY/SFATFJZIP <br /> SUB ATEA Tdn PHONE <br /> SUBC W.' ORADD"M CRY/STATE/ZIP <br /> LICENSE ❑C-57 ❑Cfil ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICALINPUREIATION: Coordirul. X - Y Township Range_ Section_ <br /> INrenDLD URE ❑DomesliNPrivate ❑Inigdion/Agricultural ❑Industrial ❑Water Qusary Monaunng ❑Soil Sampling/Charaetenaauon <br /> ❑Public Water S}}l1tem <br /> Irdinnrnt ram Oamer. .m me <br /> num .11Eme vn .mew u <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Altemuon/ModificauDn ❑Othtt <br /> ❑Monitoring Wells) Ifofwells [3 Soil Bon.g(s) 9oftonrp ❑GeocechniW ..fwa, <br /> 3kWt-0f-Service Well E3OuI-0F-Smite Well Renewal ❑Crts-Connettion Repair <br /> C!New Pump 13 Pump Rc,plactuxen, ❑Pump Re it <br /> WELL CONSTRUCLION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary 13 Ms., ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Exevauon in diameter C!Open Rouom [3Gravel Pack/Grave)Size mdiameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel ❑Plastic Cl Stmnles Steel ❑Other <br /> Grout Sea] Depth ft ❑Neal Cement(94 11,bog/J-10gol Carer) ❑Send Cement lurk m¢17 Ed water <br /> ❑Bentonite(20%solids) Cl Manufaetu er Spec%solids_% Name ❑Spats em File ❑Specs Submitted <br /> Grout plenment Meltual O Pumped ❑Free Fell ❑Other ❑RetaNant/Accelerator(name) <br /> PEDFSI'AL Installed By ❑[hiller ❑Pump Contractor ❑ Other <br /> ❑Couerete PMeWI Dimensions:Width R Length R Thick in ❑Christy Boa ❑Sbve Pipe <br /> PLTIP ❑Submnsible O Turbine ❑Other HP Pump Set ft Standing Watt Level R <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOU ADVANCE NOTICE <br /> /REQUIRED <br /> FOR INSPECTIONS <br /> SIGHED <br /> TITLE <br /> pE_/e/�^�'✓ DATE L —6 Q7 <br /> I <br /> 5 <br /> q O <br /> E q <br /> TMENT U E NLY //f <br /> Application Accepted R7 \N'N V M I Date q�6 Aro Employee IDN ! <br /> Grout Inspection By Dace ❑ SPECIAL Well Permit <br /> L2r•J -'n-pr�B Date /> e9 ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> i <br /> J ff.�{ <br /> CIEPE SC Reserved hschlt Amount Mte PerMt/ I0v01.N Well IDN <br /> Info B Cash mkted SerWeeR uea]N <br /> e <br />