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V� La <br /> WELL / PUMP PERMIT <br /> SAN JOAQ— COUNTY NTAL HEALTH DEPARTMENT 304 E WEBER AVE 3a°FL-STOCKTON CA 95202 - (209)469-3420 <br /> NON-REFUNDABLE PERMIT CALL(209 95J-7697 1Y)R INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �( f <br /> CrrY/ZiP —- 1—= �_ <br /> JOB ADDRESS <br /> CROSS STREET �� APN /2 77—" J /P/-�RCEL SIZE • LAND USE APPLICATION a z <br /> OWNER NAME - � �1� �� ) Kl�.r I` CiC C L{•�t"ilC� PHONE <br /> OWNER ADDRESS i -/k/ CITY/STATEJZIP <br /> h <br /> C •� PHONE — 5 <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS � CITY/STATE/ZIP <br /> PHONE <br /> SUBCONTRACTOR - <br /> SUB('ONTRACTOR ADDRESS CITY/STATEJZIP — <br /> LICENSE C-S7 b"(-61 ❑f)-w% ❑l)cher _ NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates \ Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charactenzation <br /> ❑Public Water System __ __ <br /> If different from Owner Water System Name omtict time or ne Number <br /> Tv Pt:Ot%N ORh ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other _ <br /> to of hmngs13 Geotechnical of honngs <br /> ❑Monitoring Well(s) #of wells ❑Soil Borings) <br /> ❑Out-Of-Service Well ❑Ou -Service Well Ren ❑Cross-conn ionRepair <br /> ❑New Pump ❑Pump Replacement "mp RS2ir <br /> a <br /> N LLt.CU��TRI c"IIU� <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Propowd Nell Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing -in diameter / Conductor Casing Depth - fl <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth R ❑Neat Cement(941h hag/S-10ga1 water) ❑Sand Cement s"k mix/7 gal water <br /> ❑Bentonite(2(r/o solids) ❑Manufacturer Spec%solids % Name _ ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Co etc Pedestal Dimensions Width R Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP MrSubmersible ❑Turbine ❑Other HP Pump Set �ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICE,NSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M : 'IM 24 H l R ADVANCE NOTICE QIiIR -D FOR INSPECTIONS _ <br /> SIGNED <br /> TITLE ��1 DATE <br /> i <br /> Ali r <br /> V <br /> r -Ti <br /> 7 <br /> D P . R TM ENT USE N L Y <br /> . 1 <br /> Application Accepted By Date Area <br /> _ Employee ID#`� / <br /> Grout Inspection Date — ❑ SPECIAL Well Permit <br /> Pump Inspection / Date111;"711, 13WAIVER Received <br /> Constructed Well Depth A <br /> COMMENTS /GCZ't-u}S Aa72e-Y 66111k�-j l-iezV 2t.r G - <br /> r�� ^SC141rUjh L6 zrA <br /> i <br /> PE SC Received heck# Amount Date Permit/ Invnice# Well ID# <br /> Codes Info By t as Remitted Service Re nest# <br /> 'Noel5 `^ r <br /> E3iD 43-02-Wr <br /> j�(= - / /..�9rZ—,7'it /�Ji't• E LPtIMP PERMIT <br /> t' Lt�/ick' <br />