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< �JOAQW4 <br /> WELL 1 PUMP PERMIT [ " <br /> COUNTY ENVIRONMENTAL HEALTH LATMENT 304 E WEBER 3 FL-STOCKTON r 5 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS .. 1 I U I C-t-4 fY RA -__ --- CITYIZIP O0.dd I lr 7 1 33 a <br /> ,f e <br /> CROSS STREET LCm.- ('�2_ _APN 2211 -2-2,0-2-41 PARCEL SIZE At'rUND USE APPLICATION# <br /> OWNER NAME �! L D -�-1'C1 �{ PHONE X_ / <br /> OWNER ADDRESS ��� � 0 ` k CITY/STATE/ZIP M Qd e!;4-0 4-C C C" 9! J <br /> CONTRACTOR I Is D r� � 1 �11 S PHONE 5 ZZ- 19 2 <br /> 0 <br /> CONTRACTOR ADDRESS CITYISTATEIZIP I Y LOCI e.�4-c3 ., Col. 911)� <br /> SUBCONTRACTOR PH <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP n) i Pj v/ <br /> f <br /> LICENSE �21`C-57 ❑C-61 ❑D-09 ❑Other NUMBER "Q�62.7 EXPIRATION DATE47:_�:Ibl fly <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private --glrrigation/Agrieuttural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System r, <br /> If different from Owner: Water System Narne Contact Nam or Phone Number V <br /> TYPE OF WORK"AgNew Well ❑Replacement Well ❑Well Aiteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings, CIGeotechnical of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal .❑Cross-Connection Repair <br /> ❑New Pump ❑Pump REplacement ❑Pump Repair D <br /> WELL C2NEERVCTION <br /> Drilling Method Mud Rotary YgIry ❑Aug,,'' 11r� ❑Cable Tool 17 Push Paint ❑Other <br /> Proposed Well Depth L44 d Excavation L Y in diameter ❑Open Bottom. gavel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diamete 'n Thickness/Gauge/ASTM Sched LIC) ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth OI ft ❑Neat Cement(9416 bag 15-l0 gal water) ❑Sand Cement sack mix/7 gal water <br /> N9t:Ben Hite(20° solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Crout Placement Method mped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> 'PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft 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 M1' 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> tt <br /> SIGNED ��C�� �M.-�� TITLES ,�A x-P r- DATE <br /> T 7a <br /> JCA Ui COUNTY <br /> N R N EN <br /> r I � <br /> 1 <br /> IT-I�14I.: N T -U, EI.- -L_Y <br /> Application Accepted B �` t Date ` Area Employee ID# �� <br /> Grout inspection By Date !r aw, ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS (�, !� G <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info 13 Cash Remitted Service Request# <br /> S` ' V.161 SRI* 490-32GU <br /> EHD 43-02.006 WELL POMP PERMIT <br /> 1/2712005 , <br />