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. . J�• A WELL 1 PUMP PERMIT .�- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3`°FL-STOCKTON CA 9$202- (?09)458.3420 NON-REFUNDABLE PERMIT r CA.,I.,(209)953-7697 FOR INSPEC'I'ION$ EXPIRES 1 YEAR FROM DATE ISSUED F, C J c/��O} JoBADDRESs 5 Cl7'Y21P 7�C�r�ry-+ / ��,/<�-'._ y CROSS STREET 1 A1PN f �,�(J�O 7�I PARCEL SIZE 31 QG LAND USE APPLICATION#�J Z * OWNER NAME —✓y7 i PL re, Tqa t,e A MY1 A-i _ PNO JNE��I S'T OWNERADDREss _R p' Lox- 71000 __ CITYISTATE(Lir--&C.rOC CONTRACTOR nntltl�j C� Z n C_ //�� I / �}Z -- PHONES!) 8'.35--0610 CONTRAc ADDAESs;80-0 A), I G4 YJryor. 5k*3 CTFYISTATEIZIF -AC �II�9J`� 76 SuBcoN'ERACTOR PHONE l!O$ • � _ 733! �Jo SUBCONTRACTOR ADDRESS -s 06 4.1Gt 1� CMISTATE21P -A-,In LICENSE S7 ❑C-61 ❑D-09 ❑Other NUMBER T7"i 1 jjEXPIRATION DATE GEOGRAPHICALINFORMATION: Coordinates X V "A Ra a F FF ectipn INTENDED UsE ❑DomesticlPrivale ❑Irrigation/Agricultural ❑Industrial (3 Water Qualidost S inglC aeter p"-ti 1 -EP ❑Publie Water System o-e u er If dict m Gxn nu: arer 5'eem ame ontaur eme or TYPE OF WORK ❑New Well ❑Replacement Well ell Altera von/Modification ❑Other n v € out g(,r_ aott,cr;ar� ❑Geotechnical ❑Monitoring We11(s) #of wells ,Soil Bann s ,�Af ❑Out-Of-Service Well Out-OfS ell Renewal ❑Cross-ty a ik ,R-ata g e a m p I ate U o r i ected ❑New Pum ❑Pum Re lacemeot ❑Pum Repair WELL CONSTRUCTION �vranm:. ._a ear I�,i 'IOrI Drilling Method ❑Mud Rotary ❑Air Rotary .Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth_ft Excavation � in diameter ❑Open Bottom ❑Gravel Pack!Gravel Size in diameter ❑Conductor Casing in diameter I Conductor Casing Depth ft Well Casing Diametcr in ThicknesslCmigelASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seel Depth R eat Cement(941h bag/5-10 gal waler) [ISand Cement sack mix!7 gal water ❑Bentonite(20%solids) Manufacturer Spec%solids % N1a ❑Specs on Fife ❑Specs Submitted Grout Placement Method ❑Pumped [}�,F'rce Fall Other v d [ar ant ccelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other Q Concrete Pedestal Dimensions',Width R length R Thick in ❑Christy Boz ❑Stave Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level R 1 HEREBY CERT[FV THAT i HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. M 24 HOUR ADVANCE NOTICE:REQUIRED FOR INSP IECTIONS S/ SIGNED TITLE \ &eo -5 t . DATE EN00Y NED t .p u�.r co 7. �MENTAt S�SO �� I EN wcf 5..A.Wa'cd.am.SsrsSwY w.xz _L // DEP-A RT ME NT rSE ONLY 1j. /c(q Application Accepted By Date !(I I jo� Area Employee ID# Grout Inspection By Date [I SPECIAL Well P¢Troil Pump Inspection By Date I] WAIVER Received Constructed WellI)pt ft I COMMENTS I s`' PE SC Received Ch Amount Permit! Invoice Well IDN Codes Into Pzn Cash Remitted A1e Service Re uest# a WFI.1.PUMP PFPM7 EHD 63�2rxw 1/1Vvk.$