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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE(PERMIT ) p CALL(2�9$3-7697 FOR INSPECTIONS EXPIRESp1 YEAR FROM DATE ISSUED <br /> 'Jos ADDRESS 1-J (.t/. LtF1JER�L� c,YrzIP <br /> CROSSSTREET PF IT RD. Ali Q2-`►-OZp-O PARCEL SIZE 4S.4I LAND USE APPLICATION# <br /> (OWNER NAME /V ( .fPHONE_. <br /> OWNER ADORCSS Z I T/Z. / f}y_ _ CITY/STATE/ZIP 1-4'O/'/' 6e 9S Z,4 2- <br /> CONTRACTOR IL1EiL O.ANUE25Jo►1 r(�sSaC. INL. PHONE ,T- 3to� <br /> CONTRACTOR ADDRESS q02- I�JptIST 4L L-J44 _ CITY/STATFJZIP L.O101, C44,9SZ42_ <br /> SUBCONTRACTOR PHONE _ <br /> SUBCONTRACTOR ADDRESS CIT/`Y1$GTATE(ZIP <br /> LICENSE *-57 IJ C-61 f D-09 7 Other NUMBER (9t0 f OQ� ExPIRATIoN DATE 01109 <br /> GEOGRAPHICAL INFORMATION: CoordlnatesX Y Township_ Range Section <br /> INTENDED Use DonteSti(JPRVate L Irrigation/Agricultural F Industrial C Water Quality Monitoring XsOl Sampling/Characterization <br /> Public Water System - + , <br /> 'f different from Owner - er ys em ame -d'Qame•ir ne um r <br /> TYPt OF WORK -1 New Well f Replacement Well C Well AlterationlModification 7 Other <br /> Ct Monitoring Well(s) _—#ofwelis Soil Boring(s)17 19 bonrjs Geotechnical s°!porlllpy <br /> 3 Out-Of-Servioe Well L Out-0f-Service Well Renewal -i Cross-Conne.:fion Repair <br /> C New Pump J Pump ReFlaoement i Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary I Air Rotary X2<Auger C Cable Toot - Push Point - Other <br /> Proposed Well Depth-10 ft Excava5cn--(4> in diameter i_ Open Bottom F Gravel Pack/Gravel Size In diameter <br /> Conductor Casing in diamater / Conductor Casing Depth . _ft <br /> Well Casing Diameter in Thickness/Gauge)ASTM Sched_ I Steel C Plastic U StainleSS Steel J Other <br /> Grout Seal Depth ft r Neat Cement(94/b bag/5- gal water) S d Cement sack rdi:xl pal water <br /> _1 Bentonite(20%solids) XOther � N( �(„LE]71 IL jv/ori4S <br /> Grout Placement Method 7 Pumped f Free Fall L Other UW Retardant fAccelerallor(name) <br /> PEDESTAL Installed By C Driller i Pump Contractor 'l Other <br /> r Concrete Pedestal Dimensions:Width ft Length It Thick in I Christy Box _ Stove Pipe <br /> PUMP -:Submersible%. Turbine Other _NP Pump Set ft Standing Water Level ft <br /> 1 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 /> IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ^] t p <br /> SIGNED TITLE � �C�/ `A.I���C� D -7ATE_ -2-4-00 <br /> • Botarlt ,-- <br /> Jwrr,.Rd_._ Tlxrar Rir- <br /> at <br /> Ifaronst Z` <br /> M. <br /> I n <br /> I — �C <br /> i <br /> itJ AQUI U TY <br /> NT <br /> I I I i <br /> W SryeK R7 <br /> S �-.il....!, <br /> 'p.. .L,i.:1 <br /> E RT ENT U/S E 0,114LY 9 <br /> Application Accepted ) Date Area Employee ID� <br /> Grout Inspection By Date -7 SPECIAL Well Permit f <br /> Pump Inspection By 7 C WAIVER Received I <br /> Soil Boring IrLspecti Date_ Constructed Well Depth -�—i< <br /> COMMENTS (1',-/r ('.iGi° <br /> -9'.-'�_2__��_7`>-ErI--AAs' - -rsf"CGL�J �-':s�/-3s�.-��.a/`.�-C�li��C�'�7�i• 4�S" <br /> PE SC Received <br /> Codes Inio B Cash Remlttad Date P !1ntvIci�c;e* 'WON(Gar <br /> IL <br /> EHD 4306 <br /> 929107 <br /> WELL(PUMP PERMIT <br />