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WELL/PUMP PERMIT <br /> SA*,IOAQUIN'COUNTY ENVIRONMENTAL HEALTH DEPARTMENT c00 EAST.MAIN STR'-ET-STOCKTON CA 95202 -(209)466-5420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR iNSPEC,TION: EXPIRES 1 YEAR FROM DATE ISSUED <br /> �t � N <br /> Ao ADDRESS E! D I 1 ` _ CITY2 �1P_ C/ L m <br /> D <br /> (CROSS STREET - • APN f X_PARCEL SIZE LAND Use APPLICATION# m <br /> IOWNERNAME �12 / QLD. �LCn PHONE r—�72cl' y <br /> !04tiNER ADDRESS 1 v D n `l-' CITY/STATE21P <br /> CONTRACTOR A l'X/ rs 2��L/x' �C�(l'f- -".�, PHONES^ <br /> CONTRACTOR ADDRESS �f=�6.r-14r" CITY/STATE21P -7 / <br /> !SUBCONTRACTOR Cot L`R a���� PHONE L- — <br /> ;SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ;LICENSE 57 C-61 :_0-09 Other NUMBER aEXPIRATION DATE 6-1 <br /> GEOGRAPHICAL INFORMATION: Coordinates X y Township_ Range <br /> Section_ <br /> INTENDED USE Domestic/Private irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> i <br /> It dlrlem"I eom Owner weer ys em ale on an Name or PriortNumoer <br /> TYPE OF WORK ,,New Well = Replacement Well Well Alteration/Modification .Other <br /> Monitoring Well(s) #of wells Soil Borings) d of borings Geotechnical z nr borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> -c3ew Pump =Pump Replacement Pump Repair <br /> WELL CONSTRUCTION <br /> ;Drilling Method-<(Iud Rotary Air Rotary Auger Cable TDO[ Push Point Other <br /> !Proposed Well Depth-726 DD ft Excavation in diameter Open Bottom then ravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth_ / It <br /> .:ell Casing Diameter in Thickness/Gauge/ASTM Sched•Y...L),� Steel�Ia�dticStainless Steel Other <br /> Grout Seal DepNO ft Neat Cement(9 S Ib t ary5 10 gaf avatar) ent /��,'� sack mix/7 gal water' <br /> Bentonite(20%solids) - Other <br /> Llout Placement Method><Pumped _ Free Fall - Other Retardant I Accelerator(name) <br /> PEDESTAL Installed ByC3riller Pump Contractor Other <br /> I` Concrete Pedestal Dimensions:Width ! It Length ft Thick in Christy Box 7 Stove Pipe <br /> 'PUMP Submersible.'Turbine _ Other HP Pump Set 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 IN COMPLIANCE WITH ALL <br /> YORKERS COMPENSATION LAWS. <br /> MIN UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS _ <br /> .SIGNED—� 't.L.` TITLE_�/W/"t r DATE <br /> r - - <br /> -- <br /> - - <br /> i - <br /> H <br /> I - <br /> i 1 - E T <br /> F 1t 44 7j 7E <br /> L <br /> 9y <br /> � 3 - 3"#4.f� 1 <br /> - <br /> 331 <br /> L <br /> DEPARTMENT USE N L Y <br /> Application Accepts ate ' Area Employee ID <br /> Grout Inspection B Date ` / _ SPECIAL Well Permit <br /> Pump inspeCl10f1 B Date / �� _. WAIVER Received <br /> Soil Boding Inspection By/ Date Constructed Well Depth ft <br /> Ct IM,LENTS (�(1Qr 6R �n r n s i ! t/1/ tom• /'Ci'rt ,_1 <br /> PE C Received C .-CtNWW Amount <br /> Codes Info By Cash Remitted Date Service Reqnest# Invoice# Wall ID# <br /> - --- - - <br /> 761, <br /> ' WE:L'PINAP PERM? <br />