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)- F3 2 <br /> WELL/PUMP PERMIT ! - F,, t ED <br /> SAN JoActulN COUNTY EwRoNMENTAL HEALTH DEPT 1868 East Hazelton Avenue-SToCKToN CA 982055232 -(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> (� <br /> Joe aDOREs8 Sfoc --&r) 962 15 9 <br /> ! � t✓1~ �Q Cmr2tP_ p <br /> CROSS STREETa k r R APN_ PARCEL SIZE 5. 51 LAND USE APPL1cATioM#© A <br /> OWNER NAmE �Q�11Yl Sp��(` PHONE 4.4- <br /> OWNER ADDRESS CtTY/STATE21P <br /> CONTRACTORPmp--q!j!()ricToN MOTORWOgX <br /> IEtD361>. 209-46b-9625 <br /> CONTRACTORADDREss 646 S. California Street CITY/STATE/LP Stockton, CA 95203 <br /> SUBCONTRACTOR SA M E PHONE <br /> SUBCONTRACTOR ABOREBs CITY1STATEMP <br /> LICENSE . 0 C-57 9 C-61 00-09 0 Other NUMBER .724778 EXPIRATION DATE 08/`1 <br /> A <br /> GEOGRAPHICAL INFORMATION: Cooi-dtnates X Y Township Range Section <br /> INTENDED USE RDomestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> It ditrerent from Owner --Water me UOMM NaMe orNumber <br /> TYPE OF WORK O New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other r u <br /> cob <br /> 0 Monitoring Wells) #of wells 0 Soil Boring(s) of ' 0 Geotechnical <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement X Pump Repair 0 Raise Well CasIN AR i <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger O Cable Tool ❑ Push Point 0 Other SAN <br /> .C!Inl COUN <br /> ry <br /> Proposed Well Depth ft Excavation In diameter 0 Open Bottom ❑ Gravel Pack/Gravel Size D fAl <br /> ❑ Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_ In Thickness/Gauge/ASTM Schad 0 Steel O Plastic O Stainless Steel 0 Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bagt&10 gat water) ❑Sand Cement sack m1x/7 gat water <br /> 0 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width R Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP Submersible Turbine 0 Other HP Pump Set It Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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. 1 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 COMPENSAT70N LAWS. <br /> - fi lMV0'11�,�4�i0UV-ADVANCE NOTICE REQUIRED FOR INSPECTIONS TITLE <br /> J <br /> SIGNED '' � DATE <br /> -- CECT <br /> Approximately 200 ft a t <br /> from Waterloo Rd <br /> '�'f '��'; •y. '�F k' 3'. 1 i7�t-^* 4k. 'tt -Fr ..t�.i j, <br /> i <br /> o '}r' <br /> oil ,T y t1 7 *`•"i�„'y�.i�;' f'r .4 t �4 'i:: �`♦ iy,� -- $',.. <br /> All <br /> A ATMENT U�r 0 LY <br /> � :— i g �r moi/ <br /> Application Accepted By vase Areae Employee ID#1� <br /> Grout inspection By Data eSPECIAL Well Permit <br /> Pump Inspection By Date ��� WAIVER Received <br /> Soil Boring Inspection By Date Construe Well Depth ft <br /> COMMENTSQty <br /> PE SC Received Amount Permit/ �— <br /> Codes Info BY Remitted Date Service Request# Invoice# Well 109 <br /> EMD 43-06 <br /> &04N6 WELL/PUMP PERMIT <br />