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WELUPUMP PERMIT P J <br /> oSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �'/ S4' / gJ CITr21P 1' <br /> LI <br /> gD <br /> CROSS STREET A N 01 3 U 0 U 9 __PARCEL SIZE �,y�LfA�r���pp USE <br /> APPLICATION N 37 <br /> OWNER NAME <br /> m L I G f/`1rHo�E,y �—L�� <br /> OWNER ADDRESS.�+ A / N_ CITY/STATEZP 1 �/ _ 7 (� <br /> CONTRACTOR �O_s /��L.C' IAf4 PHONE e3I- 41/!N <br /> 7 <br /> CONTRACTOR ADDRESS s CrTY/STATE/ZIP <br /> SUBCONTRACTOR P E 'B 10 I-Y13 <br /> SUBCONTRACTOR ADDRESS Cr'T^Y�/STATE/LP <br /> LICENSE tLe-57 C-61 D-09 Older NUMBER F EXPIRATION DATE C G� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y_ ownship_ Range Section_ <br /> INTENDED USE Domastic/Private Irrigation/Agricultural Industrial Water Quality Mo 'oring Sal Sampling/Characterization <br /> Public Water System <br /> It different from Owner: WaterSystem Name CorIlactAame�or hone Number <br /> TYPE OF WORK >{lew Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) M of wells Soil Boring(s) r W borings Geotechnical r of borings <br /> Out-Of-Service Well Out-Of-Service Well Ren al Cross-Connection Repair <br /> New Pum Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethotMud Rotary Air Rotary Auger Cabydiamer <br /> sh Point Other <br /> Proposed Well Depth 7W It Excavation�_ Open Bottom Gravel Pack/Gravel Size In diameter <br /> Conductor Casing In diameter / Conepth ft <br /> Well Casing Diameter_�in Thickness/Gauge/ASTM SchadSteel 'CPIastic Stainle Steel Other <br /> Grout Seal DepB>. ft Neat Cement(94/b ba -10 gal water) �4and Cement d sack mbIff gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement MethooK Pumped Free Fell Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By X Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Wid M Length it Thick In Christy Box Stove Pipe <br /> PUMP %AbmerSible Turbine Other HP S Pump Set It Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS 6PbCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, A LES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA ACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM,24 HOUR DVANC E REQUIRED FOR INSPECTIONS-PLEASE CALL(209 953-7697 <br /> SIGNED Tm_E0 IZ44 - DATE Zf 0 <br /> N <br /> R <br /> DEPARTMENTp-USE <br /> [ ONLY l <br /> Application Accepted By Date 11 ` Area / Employee IDN WGA) <br /> Grout Inspection By Date I.I SPECIAL Well Permit <br /> Pump Inspection By Date I 1 WAIVER Received <br /> Soil Boring Ins action By Date Constructed Well Depth �fl <br /> COMMENTS TILT 71. <br /> PE SC Recel Amount Date Permitl Invoice N Well IDN <br /> Codes Info B Cash Remitted Service Request N <br /> y3 Iry Iv�gs 420 (21y Q WP0 5 q3so Iyl`lS S� 8 1 W-4OU S4 7 <br /> ,4391 1-tvis- 4s g 1 W I <br /> EHD 43'16 L�. WELL/PUMP PERMIT <br /> 41"12 <br />