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WELL/ PUMP PERMIT <br /> SAN JOAQUIN COUNT'ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AN 3"Ft.-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT (AIA, 209)9:3-7697 FOR INcPF:("I10N,� EXPIRES I YEAR FROM DATE,ISSUED <br /> LA"i T• Ckz kIk xx�ri Rd --YD. S <br /> JOB ADDRESSCITYIT.IP <br /> CROSS$TREF.T�/ -I APNi S �PANCEL 517,E 'J LAND USE APPLICATION <br /> f4 <br /> M <br /> OWTIERNAME V ki if2o _ �TPHONEC+� r ��_�QIc?��,2Qq$ <br /> OWNER ADDRESS — (Ty) CITU/STATE/ZIPL U�1y,(,Y� C�(t I J NT"7 <br /> CONTRACTOR IC�)�7� � /yi', /�`ll/ O^0 �� PHONE 2 X131-3zcl D <br /> CONTRACTOR ADDRESS "1 2/ �yI�l-V/C.� f1 ,_ CITY/STATF/ZIP ay�_�I/r�_�� <br /> SUBCONTRACTOR _ __._ PHONE .. <br /> I <br /> SUBCONTRAVC-57 <br /> .ADDRESS CITY/STATE/ZIP ,nv <br /> LICENSE ❑C-61 ❑D-09 ❑Other NUMBF.R EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X V' Township Range Section_ <br /> I!rrENDF.D CSEDomestic/Private 13Imgation/Agriculmral ❑Industrial ❑Water Quality Monitoring ❑Soil Samphng/Charactenzauon JJ <br /> bhe <br /> Watcr Sy cnn <br /> If dfrtemm from O. ___--_ amr yuem Name. nntact one w ne u r <br /> TV'PE OF WORK ❑Ncw Well ❑Replacement Well ❑Well Alteration/Modification ❑Other �1 <br /> ❑Monitoring Weil(s)_9 of wells ❑Soil Boring(s)_ ..1 hon.g, ❑Gmtechmcal o(bonnas <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> �PumE Re lacement ❑Pump Repair (� <br /> WELL ON I I N <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other I_ <br /> Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack!Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other C <br /> Grout Sed Depth ft ❑Nat Cement(94/h hag/5.10 gal%wter) ❑Sand Cement sack mix 17 gal water I C. <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec a/,solids Name_ ❑Specs on File ❑Specs Submitted 0 <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) _ O <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions Width ft Length It Thick in ❑Christy Bos ❑Stove Pipe <br /> PC_�MP Submersible ❑Turbine ❑Other HP Pump Set A Standing Water Lcvcl 0 <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN I <br /> JOAQUIN COUNTY ORDINANCES,STATF. 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> II <br /> 11 IM NI 24 HOLR:%M.ALN('E.NOTIC-:RF.QI'II F:1)POR INSPE('TIONS <br /> SIGNED TITLF. DATE ` <br /> ITI <br /> 04 <br /> D A TMENT US ONL f, n/ <br /> Application Accepted By i' >ate 2 O Area _ Lmployce IDM 7/ 7 1 <br /> Grout Inspection By_ _ Date_ ❑ SPECIAL Well Permit <br /> Pump Inspection By 7a —T, _ Datejo� �_� ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS_i�L�,yWe�/ L.o00.�...... r��k. �fiA+�Jf-r fu-'0? d )A-w� .--..---.....__......... <br /> PE SC Received Check# Amount Date Permit/ ImolceM Well IDM <br /> Codes I Info B Remitted Service R uest M <br /> c Sa o <br /> EHD 0-02.006 WELL PUMP PERMIT <br /> V27/200i <br />