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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 /> 1I!-,NON-REFUNDABLEI PERMITS" p CALL(22�953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 'JOB ADDRESS rt�/�0pO y{/, r(rt/c J.�E2_ p ._ _ CITYrzIP__�O f 9�L¢ f1 <br /> CROSS STREET R IT yD. APN�Z r'OZO O Z PARCEL SIZE 45.41 LAND USE APPLICATION# <br /> OWNER NAME _f�E�C/�[I l f f /1 Wo PHONE <br /> OWNER ADDRa SS Z 14$L �jE}-`•'IQ��/� CITY/STATEfZIP �Q�, f <br /> CONTRACTOR OC-IL O.A�pE(25or„}t�sgc�.� 1N�. _ PHONE_2,.>1- 3( '� <br /> CONTRACTOR AoDRhm OL INDtfT T7Clh L- w44 _ CmtSTATE21P_ G.OQI t C64 45242- <br /> SUBCONTRACTOR PHONE___ <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE -57 J C-61 _F- D-09 n Other _ NUMBER-(0-(09 00 4 EXPIRATION DAT[ 109 <br /> GEOGRAPHICAL INFORMATION: COordlnaLBS X Y Township Range <br /> Section_ <br /> INTENDED :_DomesticJPrivate I_ Irrigation/Agricultural r Industnal Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water Sys;em <br /> 'f different from Owner - water <br /> ys em NdFM <br /> TYPE OF WORN -1 New Well r Replacement Well C Well Alteration/Modification F Other <br /> Monitoring Well(s)___#ofwells KSOil Bonng(s)1_ If of btirirhs Geotechnical #ofborirps <br /> Out-Of-Service Well I Out-0f-Service Well Renewal J Cross-Connection Repair ' <br /> L New Pump J Pump Replacement i Pump Repair C <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 1 Air Rotary ><Auger C Cable Toot ' Push Point - Other <br /> Proposed Well Depth--O ft Excavation--(,:> in diameter i_ Open Bottom I Gravel Pack/Gravel Size in diameter <br /> Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched_ f Steel 7 Flastic I Stainless Steel �Other <br /> Grout Seal Death ft C Neat Cement(94 1b bag15.10 gal water) Sd Cement sack•mrx/7 gal water <br /> !Bentonite(20%solids) XOther. 96P N ii rc aca E S SO/L CIO TiN 465 <br /> Grout Placement Method -1 Pumped r Free Fall L Other _ W Rela:dant Accelerator(name) _ <br /> PEDESTAL Installed By C Onller _ Pump Contractor 'l Other <br /> I Concrete Pedestal Dimensions Width ft Length__ft Thick in L Christy Box _ Stove Pipe <br /> PUMP I: Submersihlei ITurbine J Other HP Pump Sei ft Standing Water Level ft <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 I AM 1N COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> IMUM 24 HOUR ADVANCE NO ICE REQUIRED <br /> FOR INSPECTIONS �y p <br /> SIGNED TITLE fACTC- e,*jZ1A)f�1L DATE 7 -24'Qy <br /> i _ it KM_zakien Pask I: <br /> ic.. :.1. <br /> '+Y TIP.—Rir._:=_�=mo : WTumv Rd_ <br /> S. 'r L.m•s I sr <br /> ri- <br /> S } <br /> `i <br /> h Ili 6FParR If :�- � 8 <br /> i �I I��•.;`!!�-:moi `:_ _ <br /> t J DAQUI J COUNTY <br /> '.� k'li ayes I <br /> I r:•.r ••ryr <br /> E 1779- <br /> P-AhtT E N T U E O N L Y <br /> Application Accepter! Date Area Employee ID <br /> Grout Inspection By Date I D SPECIAL Well Permit <br /> Pump Inspection By 7 Date C WAIVER Received / <br /> Soil Boring Inspecti9n C%Date Constructed Well Depth ft <br /> COMMENTS <br /> ��� -�`' / L � !.7 �,�7<�`-iC-"CL//ice G��•r71/�0%S_ <br /> PE SC Receive <br /> ec d Amount Date p <br /> CodItttb B ae <br /> Cash Remitted I— 8 Well ION <br /> 61404306 <br /> 9rNM7 WELLlPUMP PERMIT <br /> 1 <br />