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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT boo EAST MAIN STREET-STOCKTON CA 95202 -(209)468-9420 <br /> (�NON-REFUNDABLE PERMrT 6CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> i'JOB ADDRESS A.50 Wr ��Q�C.� �. CITYrzIPS <br /> f7� 9L+ <br /> I - VIII g <br /> CROSS STREET R IT Qo. APN_DZ9-OZO-o Z PARCEL SIZE-4141 LAND USE APPLICATION# y <br /> ,y -` 4 m <br /> OWNER NAME _l 'E/�qC A1C Nj PHONE Q/I��CIO _ N <br /> OWNER ADDR@85 Z( �U Z IJ- 91411 CITY/STATEIZIP <br /> CONTRACTOR tjC-IC .3 0.A1,*61Z Or/���SASoC.� Ih1C. _ PHONE� 1 <br /> j ^ 3S-7 9-oI <br /> n. <br /> CONTRACTOR ADDRESS -IOZ IN+�u5T1Cj4I- wry _ _ CITYISTA7e7lP C.00I, CO grj 24� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS _ _ CITY/S <br /> TATE/ZIP <br /> LICENSE -57 ❑G61 ❑D-09 7 Other NUMBER WW /t70 4 EXPIRATION DAT@ 109 <br /> GEOGRAPHICAL INFOIWATION: Coordinates Y Township- Range Soclion <br /> INtENDED USE C DomesticiPrivate C Irrigatlon/Agricultural r Industrial C Water Quality Monitoring Xsotj Sampling/Characterization <br /> C Public Water Sys;em <br /> Nrm <br /> ditfa !t from Owner - er ys em Name QOrdad Narre,Dr PhOM Number <br /> Tyne OF Won K D New Well C Replacement Well C Well AllerafioNModification r Other <br /> p or borings <br /> C Monitoring Well(s)__#of wells Soil Borings) 7- I Geotechnical #of bvings <br /> 7 Out-Of-Service Well C Out-Of-Service Well Renewal J Cross-Connection Repair <br /> ❑New Pump ❑Pump ReGlaoement FI Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary I Air Rotary )--Auger C Cable Tool 7 Push Point C Other <br /> Proposed Well Deptq0-j b R Excavation_ jo n diemeter U Open Bottom ❑Gravel PacWGravel Size in diameter <br /> Conductor Casing In dlameter / Conductor Casing Depth _ft <br /> Well Casing Diameter in Tnickness/GaugWASTM Schad C Steel C Plastic J Stainless Steel J Other <br /> Grout Seal Depth ft C Neat Cement(9411bb W5.10 gal water) C Sa1nd Cement sack-rr 7 gal water <br /> Bentonite(20%solids) )<Other a�I� AJ I� �Z4IE / SyIG U0T/A.145 <br /> Grout Placement Method :)Pumped - Free Fall C Other W G Retardant Accelerator(name) <br /> PEDESTAL Installed By C Driller n Pump Contractor -1 Other <br /> F,.Concrete Pedestal Dimensions:Width R Length ft Thick in I_.Christy Box -Stove Pipe <br /> Puwp r SubmersibleF.Turbine :u Other HP Pump Set ft Standing Water Level R <br /> I 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS �y <br /> SIGNED TITLE � �% �itJLI�t�E/L DATE 7 -G4~�8 <br /> I I <br /> ,!. 'KAIz7kie P�k <br /> - __._. �YYSMMrt�' - ...S. :*rTu!nernir.�:'(((_ 7AJTv!narRd- <br /> O <br /> %4 J A UI U TY <br /> _ %, 41 1 <br /> NIT <br /> E ENT U E N L Y <br /> Application A.ptW BTq. Date , Area Employee ID k!F- A <br /> Grout Inspection By Date 7 SPECIAL W911 P81177ft (� <br /> Pump Inspection By a 7 DateWAIVER Received <br /> Soil Boring Inspectl n •-Date Constructed Well Depth ft <br /> COMMENTS"E_:lt C?iP✓�- SsY[>y/ /l//i�: .4'71J�71e�C.r Fie t % << lei 7! C`�CE � ijL� <br /> C�•r7Jr�d��5- <br /> PE Se Received Amount Ek" egInvoice 8 Well ID# <br /> Codes Info By Cash Remitted <br /> EHD 43-06 WELL(PUMP PERMIT <br /> 92a'07 <br />