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Th Fki„J� 5 Lkn 11-10 -16 05►-1 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENNRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 96205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe AD E9s 1`Li�"T1 T1� L `SVA W CtTYZP L l n; c) C V l �I j x2 J C- D <br /> CROSS STREET K, S 1\ � ) RT7 APN')�� �'/2- <br /> -4 oo PARCEL SIZ/E�� 14'USE AP(PLICATON/ <br /> OwNERNAME r l r�C+ �IS'(�C" l /C)kC'-C' <br /> l(PHO`NEL31�'7 - ���A C'K' W <br /> OWNER ADDRESS C{I `'„i \ 1 z \V CRYISTATEIZP C/G <br /> CONTRACTOR �t 11 e. y f 1 ') 'o PHONED /I <br /> CONTRACTOR ADDRESS �. C. L X t CrrY/STATEfZP G Irl1�) CA C{1`�7 l�, �2 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATE/LP <br /> LICENSE �C-57 C-61 _D-09 _ Other NursER"r� ExPtRAnON DATe - 1 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED UsE =DomesticlPrivate 'A Inigation/Agricultural =Industrial =Water Quality Monitoring -Soil Sampling/Characterization <br /> Public Water System <br /> IfdR•fM*om Own•r. WNW, m m• C.,Ud 14erre or <br /> TYPE OF WORK New Well --Replacement Wed -Well Alteration/Moalftation Z Other <br /> -Monitoring Wel(s) *of wells _ Soil Boring(s) e or bodrgs _.Geotechnical s of bonrgs <br /> Out-Of-Service Wen :Out-Of-Service Well Renewal -Cross-Connection Repair <br /> New Pum C Pump Replacement -Pump Repair Raise Wen Casing <br /> WELL CON3TR A&MON _ <br /> Drilling Method Mud Rotary - Air Rotary -Auger Cable Tool - Push Point - Other I/d <br /> Proposed Well Depth r7C•C: R Excavation I'fk _in diameter -Open Bottom �(Gravel Pack/Gravel Sae— diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter� in Thickness/Gauge/ASTM Sched -Lt.' -Steel X Piestic _Stainless Steel -Other <br /> Grout Seal Depth SIL) R =Neat Cement(941b bag6-10 gal water) Sand Cement C sack mix17 gal water <br /> -i BentonRe(20%solids) Other <br /> Grout Placsmsnt Medlod XPumped Free Fall _Other _Retardant/Accelerator(name) <br /> PEDESTAL Installed By4 Driller _Pump Contractor.v 011ier <br /> Coronets edostal-Dirnensions:Width J R Length R Thick - in -Christy Box -Stove Pipe <br /> PUMP Submersible-Turbine -Other HP= Pump Sat R Standing Water Leve{ R <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. 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FO`Rl INSPECTIONS-PLEASECALL(209)953-7697 <br /> SIGNED -s'r� TITLEy �C }�1 :' S,C� Iftl T DATE 7 �X� <br /> I NIP, <br /> I q4 <br /> J 2 © <br /> N�q�UiN <br /> � a I I, Ty ao�A�l <br /> lley <br /> 7T1 -17-17 Y>,V7 <br /> DEPARTMENT USE NLY <br /> �`L _,.r r <br /> Application Accepted By Date Area J� Employee <br /> Grout Inspection By Date 7 SPECIAL all Permit <br /> Pump Inspection By Date D WAIVER Received <br /> Soil Boring Inspection By Date Constructed Wen Depth R <br /> COMMENTS <br /> PE SC Received ChockV Amount Date PermiU Invoice N Well IDN <br /> Codes Into B Cash Rsmthod SerykfRequest N <br /> (- -.1 P- 7N C/-o <br /> L� L7 J 0 <br /> / i e- WELL/PULtPPERIA:T <br />