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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 95202 - (209)466-3420 <br /> • NON-REFUNDABLE PERMIT CA 1A, 209 953-7697 FOR INSI'F(-I'IONS EXPIRES I YEAR FROM DATE ISSUED H <br /> JOB A DDRESS <br /> 2-1 53. CrrY/ZLF <br /> � <br /> 0 <br /> Q / <br /> • <br /> CROSSSTREET I Gi�,l� APh' U Z3 �' C 6—PARCEL SIIIC)t LAND USE APPLICATION N � <br /> OWNER NAME �f ` V`t G S I PHONE i <br /> OWNER ADDRESS CIT'/STATE(LIP // /Q //�� <br /> LZfq 5')`-j <br /> pi�1 FICA(� �L INC <br /> PHONE I—�� ZG8 01-t61 <br /> eawCONTRACTOR ADDRESS ( (�00' <br /> Q A 11 W`�� i L �" Cm/STATUZEP'QKL f�NON CA 9 -16- 1 <br /> SUBCONTRACTOa I At IL's'\ 1 (N V I I_1 + PHONE 1 6 / V�'l <br /> SUBCONTRACTOR A DDRE55 3� I( Vr L I Cly('I ( CCT` <br /> I/TY/STATE/Lff LC M <br /> C C�/99 C ✓S <br /> LICENSE ,-57 C:)C-61 [I D,09 ❑Other NUMBER I v 6 2 10 Expi RATION DATE <br /> (05 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE ❑Dorn-tic(Privatr ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring oil Sampling/Cluracteriution <br /> ❑Public Water System ont.ci rmc w <br /> If diff—I from ONrer W.I. teem rmr <br /> TITE OF WORK ❑New Well O Replacement Well ❑Well Alteratiodi fn�tion ❑Other a of boring <br /> ❑Monitoring Well(s)_#of Wells Soil Boring(s =rot b—&, ❑Geotechnical <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑NrW PumE ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth :S fl Excavation in dianeter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> O Conductor Cuing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter!f_K in ThickneWG'auge/ASTM Sched ❑Steel O Plastic ❑Suinless Steel ❑Other <br /> Grout Seal Depth fl ryyveat Cement f9a Ib bag .i-/0ga/water) �f U")❑Sand Cement s A mit/7 gal Water <br /> b Lis fc '� t ❑Specs File ❑Spers Submitted <br /> ❑Bentonite(20°G solids) Manufacturer Spec•/.solids_'/. Name a G—s <br /> Grout Placement Method ❑Pumped ❑Frec Fall ❑Other ❑Retardant/Accelerator(name) )Q C c(r <br /> PEDESTAL installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width fl Length fi Thick in ❑Christy Boa ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set fl Standin¢ Water Level fl <br /> I 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS O <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M NINIUM 24 HOUR ADVANCE NOTICES REQUIRED FOR INSPECTIONS <br /> SIGNED <br /> TITLE l 2n•j f-C-f 1(ynAI /PILL2 DATE <br /> PAYMENT <br /> RECEIVED <br /> JUL 2 6 2(- <br /> AN JOAQUIN COUNTY <br /> ENVIRONMEN IAL <br /> EALTH DEPARTiv1ENT <br /> DEPARTMET U E O N L Y c [� <br /> Application Accepted By Date <br /> N7 CS Area Employee IDN ' 3 L' <br /> Grout Inspection By Date r•7 �-L D ❑ SPECIAL Well Permit <br /> Pump Inspection By <br /> Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received ChKk/l/ Amount Permit/ Invoice Well IDN <br /> Codes Info B Cash Remitted Date Service R nest N <br /> ,2-3 L-,71) `1 0 00 L3 <br /> WELL PUNA PLRmrr <br />