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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMI.NT 304 E WEBER AVE 3"FL-STOCKTON CA 95202-(209)468-3420 N <br /> NON-REFUNDABLE PERMIT CALL. 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS •-�L47SSOr" 1 r.3t Steri'' 'f---- C]TytZIP �'1`�t`'tyTD� qs� "" m <br /> CROSS STREE / l"'r"� APN ��� .PARCEL SIZA&AINt LAND USE APPLICATION# <br /> OWNERNAME IQ�y.� f'TM1l1 r,�r`1p*�,`� ��/�f - y� PrHOO.N,Er.r�t CA� <br /> OWNF.RADDRESS t1CXr�o /��A�� rrT�L`" A`� CITY/STATE/ZIP � <br /> CONTRACTOR J,t K2""P'C�e— 1K.ft,/,TAL1'►/1 ASS(DU� <br /> CONTRACTORADDR//E��SSS� 410,�'/�` ,"` 'r' ' ��I.`�-t"r CITY/STATEIZIP �'^'�/��I\l_• RlSZ''�J�{I <br /> SUBCONTRACTOR YV�T (eAST �"K?LC9 ' Qf1A GPHONE `�9 / ' L / /1 <br /> SUBCONTRACTOR ADDRESS �.U r 17tOX 'Sl CCIITYY//SSTATE(IZIP v�4 I G' ��QZ'"� <br /> LICENSE # <br /> C-57 ❑C-61 ❑D-09 ❑Other NUMBER v /"�`"' EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System _ <br /> IfdilTerentfrom Owner W.w,yrtem .— .tsar ame or Phone N..br <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #ofwclls ❑Soil Boring(s) sofbormgr XGeotechnica aofbodiip <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth `30 R Excavation- 14 in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter I Conductor Casing Depth R <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Sicel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal DepthlS-Tb ft [Neat Cement(94 Ib bog/5-10ga/wafer) ❑Send Cement suck mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall Other T �� ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other r <br /> ❑Concrete Pedestal Dimensions:Width It Lmgth R Thick in ❑Christy Box ❑Stove Plpe 1 <br /> tl <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set R 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 V) <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS 3 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MUMM 24 HOUR ADVANCE NOTICE REQUIRED <br /> �FOORj�INSPECTION <br /> S L� a <br /> SIGNED C'// TITLE �Iytr"Cl T Ga.` %-OC-' 'T DATE 1 / n <br /> 9 <br /> N � <br /> O � <br /> 0 <br /> A <br /> ' O r ;AN <br /> ENViD PA <br /> HE T E <br /> — scoucR <br /> DEPARTMENT UE ONLY <br /> Application Accepted By_ 1,�' Date Zd o Area Employee ID#s�U�n� y <br /> Grout Inspection By Date [ISPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed,r 1 epth H <br /> COMMENTS �� � <br /> rD <br /> PE SC Received Che. Amount Date Per 11 I #— Weill <br /> Codes Info B ash Remitted Service Re cast <br /> q-3.12- 150 1 vj c�—A 192 2v �o <br /> WELL PUMP PERMIT <br /> EHD 4142.0x6 <br /> lA2Rood <br /> r �. <br />