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-7. Of <br /> WELL/PUMP PERMIT <br /> 0ANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT " ClA�LL`209 9$3-7697 FOR INSPECTION'S / EXPIRES <br /> ,I YEAR FROM DATE ISSUED <br /> JOB ADDRESS W O Is""� 1' v� V��7CITY/ZIP Lam✓/" -f�'r 9 - '-?30 <br /> ,,//� e� 0 <br /> CROSS STREET (.F-(ny FCI -APN Z 9 —O I PARCEL SIZE T ' DLAND USE APPLICATION# c' <br /> OWNER NAME PHONE <br /> OWNER ADDRESS // p CrrV/STATE/ZIP /� /ty p` ''/ �f <br /> CONTRACTOR J/0 Ciel v,Y�I /7�('��/r I (, - r PHONE 2fa �/q D—I d 0J <br /> CONTRACTOR ADDRESS �/) (if) � Uz �1�` CITY/STATE/ZIP -6q q 5-2V <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 57 ❑C-61 11D-09 ❑Other NUMBER J 1C/-T�� EXPIRATION DATE 041 <br /> GEOGRAPHICAL INFORMATION:,.Coordinates X ' Y - - Township $ange Section_ <br /> INTENDED USE O Domestic/Private ❑Irrigation/Agricultural .43 Industrial, ❑Water Quality Monitoring it Sampling/Cbaracterization <br /> O Public Water System <br /> Ifdirf—ttmm 0—r WRIff "tem Nanx ontact ame or one N.rnbe, <br /> TYPE OF WORK ❑New Well • ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> - O Monitoring WCII(s) #of wells O Soil Boring(s) °f bO0°as Geotechnical�x otborinp <br /> ❑Out-0f--Service Well , ❑Out-0f-Service Well Renewal J3 Cross-Connection Repair., <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method O Mud Rotary O Air Rotary 'C&6uger Al ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth It Excavation y'r/7 in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Stccl "'O Plastic O Stainless Steel ❑Other t -1 <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-/0 gal water) ❑Sand Cem Ont sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids %r Name ISO ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped 11 Free Fall 13cce <br /> Other - ❑Retardant/Alerator"(a!; 7Q C�� <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submetsible. ❑Turbine ❑Other HP' Pump Set It Standing Water Level - ft <br /> lHEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> OAQUIN 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 AM IN COMPLIANCE WITH ALL' <br /> WORKERS COMPENSATION LAWS. - <br /> INIM 24 HOUR ADVANCE NOTICE <br /> �R/EQUIR' FOR INSPECTIONS <br /> 'O�n� <br /> SIGNED �` TITLE (� �r/T DATE <br /> 120 <br /> N <br /> N IR N <br /> ME fo'erIMMEMINIMMEMMMIN <br /> No <br /> ME <br /> ins <br /> ME <br /> No <br /> av <br /> no <br /> on <br /> P R <br /> ` D"ME <br /> P A T M E N T S E - N L Y <br /> Application Accepted Date Area Employee I13#.45'VYS <br /> Grout Inspection By;' Date ❑ SPECIAL Well Permit / <br /> Pump Inspection By - Date ❑ 'WAIVER Received - •'• <br /> I Constructed Well Depth ft - - <br /> COMMENTS S <br /> PE SC Received Chec Amount Date PerrtdU- Invoice# Well ID# <br /> Codes Info B ash Remitted ScZRe nest# <br /> o Cs 1 iv Lo <br /> I _ _ <br /> ENDO-0I-0Ds �/ —T--T— <br /> WELL PUMP PERMIT <br /> I{ I27=5' <br />