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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DFPARTMENI 600 EAST MAIN STREET-STOCKTON CA 95202 - (2091468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> J OB ADDRESS- L<�5 wr c r< Rte. CITYlLP y <br /> `� 9 533 <br /> I CROSS STREET_ W _ _APN 1qj_04a-o(0 PARCEL SIZE �4,15 LAND USE APPLICATION tt fr <br /> m <br /> OWNER NAME 5-105 t4 <br /> {IrS�/W<�!/1� ,4 EQ� _ PI/ONE d Q <br /> OWNER ADDRESS `✓'-1✓✓ N. Pl..�- (�� !+vim- CITVISTATEILP 5 .� t,�j CA 7 S 2-00� <br /> (CONTRACTOR ME(L �_J /'T,SS-QC k, PHONE <br /> (CONTRACTOR ADDRESS qQ?— { CITY/STATE/LP L-&VI F <br /> SUBCONTRACTOR CA Cr PHONE <br /> r <br /> SUBCONTRACTOR ADDRESS I maY ha+( tTYISTATE/ZIP <br /> i LICENSE XC-57 C-61 -09 fTIL1'r 1 NUMW (0&!100 4 EXPIRATION DATE Z <br /> i <br /> GEOGRAPHICAL INFORMATION: Coordinates X - I-. Township Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultu al Industrial Oualfty Monitorina Sod SamplingrCharaclerization <br /> Public Water System <br /> IT 1MMefif T/nrr Ownnr '.q'.91*1 Nalle Zqntact Narie nr Phont, ❑m <br /> TYPE OF WORK New Well Replacement Well Well AlleralioniModification Other <br /> Monitoring Well(s) #of wells Soil Borings) r M bonnpn XGeoiechnlcal it <br /> 0 hmnor <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Conneclion Repair / <br /> _ New Pump Pump Replacement Plump Re air Raise Well Casing <br /> W LL CONSTRUCTION <br /> 'Drilling Method Mud Rotary Air Rotary XAuger Cable Tool Push Point Other ' j <br /> L ft Excavation �o in diameter Open Bottom Gravel Paciu'Gravel Size m diameter <br /> Proposed Well Depth 5" + <br /> Conductor Casing in diameter r CondUCtar Casing Depth It <br /> Well Casing Diameter_ In Thickness�Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 fh bao/5-10 gal waffen)e Sand Cement sack mxll gal water i <br /> Bentonde(20%soli dsi )(Other Sof L C q Tr lA)tl LVi <br /> IGrout Placement Method Pumped Free Fail Other _ Re•ardanf r Arcelerator inamel <br /> jPEDESTAL Installed By Driller Pump Contractor ::Ihel <br /> _ Concrete Pedestal Dimensions Width ft Length ft Thick In Christy Box Stove Pipe <br /> Pump Submersible Turbine Other HF Pump Set It 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 IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE <br /> /RREQUIRED FOR INSPECTIONS � <br /> SIGNED TITLE I,/UC,11A`-' DATE 3 - <br /> •.�'� ... � rte.` - 'Jy .,'e �-`j` <br /> t <br /> r <br /> _ 'Sr <br /> DEPAR TM ENT USE ONLY Q1� <br /> Application Accepted By Date l � M <br /> D_ Employee ID* �7's 3Gt <br />