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3 9 <br /> WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPEC i iui�,, EXPIRES 1 YEAR FROM DATE ISSUED <br /> /n '�' -1 / G � <br /> J06 ADDRESS l�D CI Prn&+$ �(� CITY/ZIP L n 9.J�V�n D <br /> CROSS STREET �` H ,1i O <br /> f1d ° 19..53^ 6"0�e PARCEL SIZE 1/1 y l.3 LAND USE APPLICATION f m <br /> OWNER NAMErust <br /> PHONE <br /> X09- 7a 7-33q9 . N <br /> OWNER ADDRESS 61 I 1 CITY/STATE/ZIP ,% _(-c m en-}n , 95- q <br /> CONTRACTOR Del fa PiirjIp tilci _ PHONE ( .1o9 ) 466-9625 <br /> CONTRACTOR ADDRESS 646 S. California St CITY/STATI1 IP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / <br /> LICENSE C-57 xC-(3D-09 C Other NUMBER 1055434 EXPIRATION DATE 8/ 16 2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private ;R Irrigation/Agricultural - Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 0 Public Water System <br /> It difforont from Owner. Water system Namo uonlact Name or Phone Iquincar <br /> TYPE_OF WORK 0 New Well 0 Replacement Well D Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of wells -- Soil Boring(s) of borings Geotechnical M <br /> 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> jFf-c' <br /> ,1New Pum 7.1Pum Re lacement Pum Repair 7iRaise Well Casin C E� <br /> WELL CONSTRUCTION 1 <br /> Drilling Method -. Mud Rotary ❑Air Rotary [I Auger ❑ Cable Tool El Push Point FJ Other OCT(� 01g <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom D Gravel Pack/Gravel Size <br /> D Conductor Casing in diameter I Conductor Casing Depth ft HEALTI j)EP'NO7A�TM <br /> Weil Casing Diameter_ in Thickness/Gauge/ASTM Sched D Steel D Plastic ❑ Stainless Steel -. Other AR71hEN7 <br /> Grout Seal Depth ft C Neat Cement(94 lb ba915-10 gal Water) ! Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method 13 Pumped C Free Fall C Other ❑ Retardant/Accelerator(Warne) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible❑ Turbine Other` HP Pump Set ft Standing Water Leveler(t <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUI14 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 /> WORKERS COMWIENUQON LAWSff . <br /> SIGNED TITLE CEO _ DATEq_ —L <br /> CALIFORNIA RANGELAND TRUST L.g..d <br /> 76-727N CLEI.ENTSPC BET,*,NhE7-TLE1.Va,3ERAN0TRr P,)I.F <br /> 1 <br /> I '1 <br /> s <br /> • <br /> EPARTMENT USE N L Y <br /> Application Accepted By Date L Area Er;ipioyce IDc <br /> Grout Inspection By Dato Well Permit <br /> Pump Inspection By Fro4u=51p ( `- )�Lw'2 Date; t 62-4 70 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received eck Amount Date Permit/ Invoice# Well IDII <br /> Codes Info 6 as Remitted Service Request if <br /> wPOO 4pai1 <br /> EHD 43•gu <br /> 8I04108 WELL!PUMP PERMIT <br />