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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-Fl.-STOCKTON CA 9S202 -(209)668-3420 <br /> NON-REFUNDABLE PERMIT CA1.1.(209).953-7697 FOR I%SPE(TIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS Cly 3�. 1 110 ZIA CITY/ZIP L b L(t 1 94711Y`/ > <br /> CROSS STREET � -�I PARCEL e LAND USE APPLICATION M <br /> OWNERNAME IVcrmaY\ �)lu.l PHONE <br /> OWNER ADDRESS :&n 1= Crn/STATVZIP <br /> CONTRACTOR 7T O /, �/7ro ss �Y,"I'1 Vl� PHONE 33E-1J— �7 Z5 <br /> CONTRACTOR ADDRESS�b •-r d1C I CITv/SIATE1ZIP J6C�Ar.l 4 r <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATEIZIP <br /> LICENSE la C-57 O C-61 O D-09 O Other NUMBER M 3�s EXPIRATION DATE l)^U f1 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Seetioa <br /> INTENDED USE O Domestic/Private O Irrigation/Agricultural O Industrial O Water Quality Monitoring O Soil Sampling/Characterization <br /> O Public Water System <br /> If differwa from Omer strrSys,— .— Co.-, sme nr Ph—Nuirb,, — <br /> TYPE OF WORK PkNew Well O Replacement Well O Well Alteration'Modification O Other <br /> ❑Monitoring Wells) M of wells ❑Soil Boring(s)g(s) M of bonngl ❑Geotechnical r of bonnes <br /> O(hit-Of-Service Well 0Out-0GServlce Well Renewal O Cross-Connection Repair <br /> New Pump O Pump Replacement O Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method 14 Mud Rotary O Air Rotary O Auger O Cable Tool O Push Point O Other <br /> Proposed Well Depth -L SAO _tl Excavation )-,� in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> O Conductor Casing in diameter / Conductor Crim Depth _fl <br /> Well Casing Demeter t in Thickness/Gauge/ASTM SchedZQ D O Steel ja Plastic O Stainless Steel O Other <br /> Grout Seal Depth h ft O Neat Cement(94 fh hog i 5-10 gel water) RI Sand Cement �,. � sack mix/7 gal water p <br /> O Bentomic,(20'/e solids) O Manufacturer Spec%solids % Name O Specs on Fi it O Specs Submitted <br /> Grout Placement Method l?"pumped O Free Fall ❑Other O Retardant/Accelerator(name) <br /> PEDESTAL Installed By IRDriller O Pump Comracto1. O Other <br /> WQ'Concrett Pedestal Dimensions:Width "I It Length tl Thick in O Christy Boa O Stove Pipe <br /> law P Submersible O Turbine O Other HP Pump Set R Standing Water Level fl <br /> 1 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 /> �//f MINIMUM 24 HOUR ADV:%NCE N07lCE,ryREQUIRED FOR INSPECTIONS <br /> SIGNED 9/ /A�� TITLE C�/�.-^.e o,— DATE /— Z-7-S <br /> T <br /> r <br /> i I I SAN <br /> i <br /> f <br /> F- <br /> L' <br /> D P A R T M E N TE L Y <br /> Application Accepted B� - _ _ Date - U 9"140�- i Area -"- —Employee 01 <br /> Grout Inspection By _ Date Sw:YJL O SPECIAL Well Permit <br /> Pump Inspection y Date - /� O WAIVER Received <br /> Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice M well IDM <br /> Codes Info B Cash Remitted Servin eat M <br /> Sr0 3 2-S W U &T j Y NU (LOGO Z(,�f0� <br /> 0 13 1� -() W z us <br /> EHD d)-0]�OM WELL PUMP PERMIT <br /> 07.120M <br />