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I r. <br /> WEI_UPUMP PERMIT <br /> SAN.IOAOUtN COUNTY ENYIP.ONMENT.aL HEALTH DEPARTMENT 1868 EAST HAZEL TON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFUMIDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �-Y Joe ADDRESS S _ 7tj__ CITYILI 9- d7 <br /> yCROSSSTREET APN �.!�YARCEL S12�LAN0 USE APPLICATIM <br /> OWNER NAMEPHONOWNER ADDRESS CITY/STATFJZIP rCONTRACTOR A�((./y� PHONE v <br /> CONTRACTOR ADDRESS r ._" - _-. CRY/STATEMP y LLIt•�[ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> UCeR/ // -57 -61 D-lam Other NUMBE , EXPIRATION DATE 7-1el _ J <br /> OEOGRAPHiCAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> IN7YNOED USE T DonxstidPOvate Irrigatlon/Agrlcultural industrial - Water Quality frlonitoring 7 Soil Sampling/Characterization <br /> Pudic Wa 3y e <br /> Il drMertmNt.,0—or Wt., y ern<arra Comaci Narre.,Pbane Tuan er <br /> TYPE OF WORK New Well Replacement Well _,Well Alteration/Mod•Aication I..Other <br /> I_ Monitoring We8($) Q Of Wells J Sol,Boring(SI u at borngs Geotechnical u of bonngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal i Cross-Connection Repair <br /> I New Pump Pump Replacement Pump Repair Raise Weil Casin <br /> WELL CONSTRUCTION <br /> Drilling Method✓Mud Re art, .Air RotaryAuger /Cable Tool Push Point '' Other <br /> Proposed Well Depth ft EXcava bon &I in diameter <Opon Bottom )rravel Pack!Gravel Size in diameter <br /> r. Conductor Casing In diameter / Conductor Casing pth ft <br /> Well cast Diamatar I Thidrness/Gau ./ASTM Schad v Steel 1 Plastic Stainless Steel Other <br /> Grout Sea Depl1 � R t�Neat Cement(94/b baW5-/0 gal water) % Sand Cement ��r sack mrxl7 gal water <br /> Bentonits(26%solids) i,Other <br /> 0roul Placement Method pod :Free Fall Other i Retardant I Accelerator(name) <br /> AL Installed By Driller a Pump Contractor G Other <br /> Concrete Pedestal, Dimensions:Width It Length It Thick in I Christy BOX I stove Pipe <br /> PUMP Submersible :Turbine .i Other HP Pump Set fl Standing Water Lcvcl _ tt <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 /> Z00jJkWANCE NOTICE REQUIRED FO/R/Qt(WSPEECTIONS-PLEASE CALL(209) 53-766K7, <br /> SIGNED TITLE !" �/ DATE[//0_) <br /> 1 <br /> / 7 <br /> Lu <br /> J T <br /> N <br /> r <br /> 4l <br /> DEPARTMENT USE ONLY <br /> Application Accepted 4Y••' �- ler I U S Area � Employee IDS �~y <br /> Y <br /> Grout Iris pedkn y r .. (Date _. SPECIAL Well Permit <br /> Pump Inspection By Date C WAIVER Received <br /> Soil Boring Inspection B Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Rectived Chtcld,�- Amount PermiU <br /> Date Invoice S Well tLh <br /> Codes Into B Gish Remitted Service Ree•rest t# <br /> EHD 43-06 WELL[PUMP PERHII <br /> 4r I? <br />