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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS - G _ CITY/ZIP � r ( e- <br /> CROSS STREET APN O�PARCEL SIZE ACNrcF 0 <br /> USi APPLICATIONATION N m <br /> OWNER NAME 1 ^^�Lr ..C-. _ PHONE 3 �C� / —! 2 CJ p <br /> �OWNER ADDRESS :1"5rd• CITYISTATE/ZIP <br /> -- �� 3�2-, 779 <br /> CONTRACTOR / PHONE[ <br /> CONTRACTOR ADDRESS A CITY/STATE/ZIP av, '2. _.?iii_ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE C-57 C-61 D-09 ":Other NUMBER ExPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y_ Township— Range Section <br /> — <br /> INTENDED USE Domestic/PrivaleIrrigation/Agdcultural Industrial Water Quality Monitoring h Soil Sampling/Characterization <br /> Public Water Sys em <br /> If different from Owner: Water System Name Contact Name or Phone Nu er <br /> TYPE OF WORK XlNew Well Replacement Well D Well Alteration/Modification D Other <br /> Monitoring Well(s) M of wells 0 Soil Boring(s) x of borings Geotechnical r m boAngs <br /> Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connecllon Repair <br /> New Pump Pump Replacement C!Pump Repair L! Raise Well Casing <br /> WELL CONSTRUO ION <br /> Drilling Method' Mud Rotary Air Rotary _ Auger ';Cable Tool ,_i Push Point G Other <br /> Proposed Well/Depth'--� It Excavation In diameter Open Bottom XGravel PacWGravel Size 1st in diameter <br /> j Conducto Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedC:/,2QQ Steel XPlaslic 7 Stainless Steel Other <br /> Grout Seal Depth jam`n It Neat Cement(94 Ib bag/5-10 gal water) Sand Cement _sack mlx/7 gal water <br /> D Bentont et (20%solids) Other <br /> Grout Placement Method I Pumped 0 Free Fall L Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By XDriller !a Pump Contractor U Other <br /> Concrete Padlastal Dimensions:Width It Length Il Thick in Christy Box a Stove PIPs <br /> PUMP Submersible':.:Turbine - Other HPPump Set It Standing Water Level h ) ft <br /> I HEREBY CE TIFY 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 /> MINIMA -24 HIODUR//ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED .+�\ r 1/ %I -1 Ih�.. TITLE.� DATE <br /> J _ C-Tl _ — <br /> (. c' t4z h to <br /> G /— <br /> .1 6t <br /> LL <br /> -7 f; _ v <br /> 5 <br /> V 14 1 <br /> CW lu I Lv IL <br /> A <br /> Is - 7 t, <br /> me u <br /> AL <br /> DEPARTMENT USE ONLY + <br /> �^ ,(y <br /> Application Accepted B VIP, r — Dale ,po <br /> 50 Area OD L? Employee IDk �.stPttc <br /> Grout Inspecllon - !i'.` �� .�� Da a ! SPECIAL Well Permit <br /> Pump Inspeclla r ^r - Dale �1 WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth it <br /> COMMENTS / <br /> r16I — <br /> PE Sc Received ChocKAh Amount Dale Permit/ <br /> InvoiceM WeIIIDY <br /> Codes Into B eZ ahs Remitted Service Reguest 0 <br /> 77 Ily3 <br /> GSb -7S( <br /> —Z'o rY-r r7. 'Fi 7✓77"c:.i /.: i 1:.. <br />