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i� <br /> WELL/PUMP PERMIT <br /> SAN JOADUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 7K(I <br /> Cm1LP L <br /> Joe ADDRESS <br /> CROSSSTREET {\I 17 APN 11 �ARCELSIZE MUSE APPLICATION <br /> OWNER NAME PCPHONE ) 1-' c, Nm8nay <br /> i <br /> OWNER ADDRESS Cl �C" �.� )\ 1\ I7• CRYISTATEMP �/-Ct' <br /> CONTRACTOR \p �-; e )' (� 1 t 1 r n [+ PHONE1 <br /> "� <br /> CONTRACTOR ADDRESS P. C. 1)C'X CIIISTATElZIP C, O I C A <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> 1 . 3� ExPnRAnoN DATE <br /> LJLENSE � �C-57 C-61 _0.09 _ Other NUYaER` _ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> IArTErDED UsE =DomestirJPrivate -)L InigatiorJAgricultural _Industrial --Water Quality Monitoring -Soil Sampling/Characterization <br /> Public Water System <br /> Irarterertfrom Owner. .r m — •e+a <br /> TYPE OF Wows )�NeW Well =Replacement Well =Well AlterationfModillcation =Other <br /> =Monitoring Wed(s) S of wells = Soil Boring(s) 0 of tbrirgs -Geotechnical a of borings <br /> Out-Of-Service Wen - Out-Of-Service Well Renewal - Cross-Connection Repair <br /> New Pump Pump Replacement -PumD Repair =Raise Well Casing <br /> WELL CONSTRUCTION _ <br /> Drilling Method Mud Rotary "Air Rotary - Auger1 n Cable Tool - Push Point -- Other t 1A <br /> Proposed Well Depth ';C-C It Excavation in diameter -Open Bottom '/k Gravel Pack/Gravel Size_ diameter <br /> Conductor Casing in diameter / Conductor Casing Depth 11 <br /> Well Casing Diameter in Thidme5VGauge/ASTM Sched LL' =Steel X Plastic =Stainless Steel -Other <br /> Grout Seal Depth GC; ft =Neat Cement(94 lb bagl5-10 pal water) Sand Cement sack mixR gal water <br /> J Bentonite(20%solids) Other <br /> Grout Placement Malhod XPumped Free Fall Other _Retardant I Accelerator(name) <br /> EJUITAL Installed By A Driller .Pump Contractor 7 _ Other <br /> Concrete Pedestal-Dimensbns:Width J R Length_'_ftThick in -Christy Box Stove Pipe <br /> IPuMP }�bmersible-Turbine Other HP •a S Pump Set �jL L R 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. 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 FOR INSPECTIONS-PLEASECALL(209)953-7697 <br /> SIGNED /te l' /-J C:,' LN-f.� TITLE DATE <br /> h <br /> I <br /> I W <br /> i IIS <br /> I II <br /> PP►��EN I I I ' <br /> r <br /> SEC 2 I I <br /> SA EKV��o Yp T I ,• <br /> l <br /> I I clle�l <br /> R b. <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 7i ZO Area "L` Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS <br /> PESC Received CheckV Amount Permit/ Involcs N Well ID# <br /> Codas Info Cash Remitted DW ic <br /> Serve a <br /> utaK <br /> _.._.--- i WELL(PUMP PERMIT <br />