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WF_!_l_/FRUMP PERMIT <br /> SAr.JOAoujWCoUNTY ENVIRONMENTAL HEALTH DEPARTMENT 500 EAST MAN STREET-STOCKTON CA 95202 -(209)458-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSi-,.�:riON . EXPIRES 1 YEAR FROti DATE ISSUED <br /> Jos ADDRESS 6 Q / -L <br /> y /f CIN/ZIP l �I`- I p <br /> ,CROSS STREET - ` APN OS1/i%IC(J1 y[ PARCEL&ZE LAND USE APPLIC/ATION# <br /> Or"ER NAME � O C.N�j I.G I �"d— PHONE J�` C��2 ri ay <br /> !OWNER ADDRESS /t CI iY1STATEfZIP <br /> .;CONTRACTOR O� ✓�+OS-S i���lX ' __ PHONE7-LS. <br /> CONTRACTOR ADDRESS GIN/STATE/ZIP (ZAD, / <br /> SUBCONTRACTOR " l`IU�Ly� PHONE� <br /> SUBCONTRACTOR ADDRESS �r CITY/STATE/ZIP <br /> LICENSE �,(�-57 C-61 D-09 .. OtherNUMBERS EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> I INTENDED USE Oomestic/Private trrigation/Agricuttural "'Industrial Water Quality Monitoring Soil Sampling/Characterizabon <br /> Public Water System <br /> UdiVererf from Owmr- Water y em ame o a ame or none umder <br /> i— <br /> TYPE OF WORK y^ew Well Replacement Well Well Alteration/Modification =Other <br /> Monitoring Weil(s) _#of wells _ Soil Boring(s) _ V of borings Geotechnical a of borings <br /> ��.tO'Ut-Of-Service Well Out-Of-Service Well Renewal - Cross-Connection Repair <br /> -+Sew Pump - Pump Replacement - Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method-Oud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth it Excavation_( in diameter Open Bottom Gravel Pack;Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth / R <br /> Well Casino Diameter �? in Thickness/Gauge/ASTM Schetl2�3 Steel lastic Stainless Steel Other <br /> Grout Seat Depth O _R Neat Cement(94 rb bag/5-10 gal water) and Cement �, sack mixl7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement A!ethotbC Pumped Free Fall - Other Retardant/Accelerator(name) <br /> PE EsrAL Installed By riller Pump Contractor - Other <br /> Concrete Pedestal Dimensions:Width_ it Lengthy ft Thick in Christy Box Stove Pipe <br /> �VP Submersible_ Turbine Other I-IP � Pump Set ft Standing Water Level R <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 NY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I A.Y. IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> // MIN�(/UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS _ <br /> SIGNED_ 1/_` ./'-7 11 TITLE_0 Uj/`& DATE 6 � <br /> - _ <br /> 3 <br /> I- 33 - <br /> + ?+E - 3 - <br /> i <br /> DEPARTMENT USE N L Y <br /> Application AcceptefB <br /> ate Area ` Employee iD# �� <br /> • Grout Inspectio �fd s ' DateSPECIAL WellPermit <br /> Pump Inspectio - Dates WAIVER Received <br /> Sal Boring Inspection By. Dale Constructed Well Depth k <br /> COMMENTS rc <br /> i=fr <br /> �PE SC I Received -911"w Amount PermiU y <br /> Colles l into By i Cash Remitted Date M Service Request# Invoice# Well 10# <br /> . WEiI'Wr.U+PERl.U7 <br />