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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS /Z lb 7i ^� !� /CL-I�Q a4rrvfZlP L Oct ! s Z'IC-0 m <br /> Tp, o <br /> CROSS STREET k+e-JE� LW APN PJSpO PARCEL S �-LAND USE APPLICATION# <br /> OWNER NAME CAG.I f=- 7--%�� !C- PHONE <br /> OWNER ADDRESS CITY/STATEMP <br /> !I CONTRACTOR PHONE -37 <br /> 7 l 2 b <br /> f <br /> f CONTRACTOR ADDRESS (9 O f✓ax- T� CITY/STATE/Z!P Z"I! 952—`7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrrY/STATFJZP <br /> LICENSE C C-57 C C-61 C D-09 C Other NUMBER ExPIRAT10N DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INrENoeD IIsE C Domestic(Private C Imigatlon/Agricultural C Industrial C Water Quality Monitoring Soil Sampling/Charactarization <br /> C Public Water System 1 <br /> I (Cif7en!nt horn Owner: Water m Nam Uonfact Name or Phone Number , <br /> f <br /> TYPE OF WORK C New Well C Replacement Well C Well AlterationrModifcation D Other <br /> 0Monitoring Weli(s) #of welts SoilBoring(s) trorbanrgs Geotechnical uofborings <br /> C Out-Of-Service Well Out-OfServioe Well Renewal Cross-Connection Repair <br /> G New Pump C Pump Replacement C Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION p., <br /> Drilling Method L'Mud Rotary C Air Rotary D Auger 7 Cable Tool C Push Point c Other Y <br /> 1 Proposed Well Depth it Excavation in diameter s Open Bottom C Gravel PaWGravel Size in diameter <br /> C Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thicicness/Gauge/ASTM Sched la Steel C Plastic D Stainless Steel s Other <br /> Grout Seal Depth ft s Neat Cement(94 Ib baglSPO gat water) C Sand Cement sack mixt!gal water <br /> C Bentonite(20%solids) s Other <br /> Grout Placement Method Pumped C Free Fall G Other 0 Retardant/Accelerator(name) <br /> QEDISTAL Installed By C Driller C Pump Contractor C Other <br /> C Concrete Pedestal Dimensions:Width It Length ft Thick in D Christy Box C Stove Pipe <br /> PUMP D Submersibles Turbine D Other HP Pump Set ft Standing Water Level k <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 IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MPIM M 24 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> I SIGNED rte. TITLE 6 J44 z& DATE /-7--,// <br /> Uv <br /> V <br /> rr <br /> I i i <br /> t + <br /> E <br /> I I ( e <br /> I e <br /> i I <br /> DEPARTMENT U E ONLY A} <br /> Application Accepted By Date -7[1-f Area Employee ID# J orf ICJ <br /> �Grout Inspection By Date <br /> ' =P* SPECIAL W@II Permit <br /> pifns�ec't�o.nye w /-_ �. � Date /�3�/i WAnrER Received <br /> Solt Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS SIG /i i1lLJ�a*�r�C'C�2i�c9G���//E Y.rL`a�4tl L9«r��L/�//litrt(r-�dG17 <br /> Ci"7 <br /> PE Sc Received Amount Permit/ <br /> Codes Into B Cash Remitted Date Service uest# Invoice# Well iD# <br /> 4377 OSV Z 3 9 n 53.-ra r 54V �? o <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 62W9 <br /> r <br />