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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY EwRONmENiAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4663420 <br /> NON-REFUNDABLE PERMIT jCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS J� 1 l Y"✓ 1 ��J � +�(�J- CI vzp TV�'`'`� �) ���� I A <br /> CROSS STREET �,l 7-,�` APN""`��J V i U.� t PARCEL SIZE I• .. LAND USE APPLICATION# <br /> OWNERNAME i Icy{`'(+'�.' W.W{�� PH1O�N <br /> OWNER ADDRESS 1)�I `1� t i '"s�1 . � CrttiST TE/Z1PY �/� i�►"'1 / <br /> CONT1?AACYOR �IIJ'fr/,'�1�61,1.(,✓7�-�,.��j...r,1�C �1V'�C.tt +r��.f�e <br /> CONTi2ACTOR ADDRPSS �.i Y rii,Y�1 77V'�C, 't+" l� • CITY/STATE,71 "-.�'st� `,}✓' _L y'-+ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATEMPP� I� <br /> LICENSE C57 L CE1 U D-09 U Other NumBER�i `-r E cpmx TON DATE :��1 L <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township- Range Section_ <br /> INT>=#OED USE OomestiC(Private 7 IrrigationiAgricutturai ❑Industrial 3 WatarRuafity Monitoring C Soil SamptinglCharadertation <br /> U Public VMarSystem <br /> It reNerara from Owrer. vvtror <br /> TYPe OF WORK )(NewWall L Replacement Well U Well AlteradoNModifcation U Other <br /> ❑Monitoring Well(s) #of wells ❑Sol Boring(s) a of bwirm ❑Geotechnical a arcorinas <br /> ❑Out-Cf-Service Well ❑Out-OfServica Well Renewal O Cross-Connection Repair <br /> U New PUMP L Pump Replacement U Plan p Repair U Raise Wail Casing <br /> WELL CONSTRUCTION <br /> Drilling Method'KMud R=aty -Air Rotary C Auger ]Cable Tool D Push Point ❑ Other <br /> Proposed Well Depth, a ft Excavation 12, in diameter U Open Bottom u Gravel PecldGravel Size-in diameter <br /> n Con Casing in d�arneter I Conductor Casing Depth it <br /> Well Casing Dfametffi in Th Gmess/Gauge ASTM Schad 1 Steal ( Plast c D Stainless Steel Other <br /> Grout Seal Depth' ft C Neat Cement(94 lb bagIS-10 gal water) ❑Send Cement sack mbd7 gal water <br /> Bentonfte(20%sd"Ws) L Other <br /> Grout Placement Method KPumped ❑Free Fall C Other ❑Retardant/Accelerator(name) <br /> PETTE JAL Installed By 7 Ddllar XPumpContractor 7 Other <br /> ❑Concrete Pedestal ODlmensions Width ft Length ft Thick in ❑Christy Bax ❑Stove Pipe <br /> Puw+ j Submarsible3 Turbine C Other HP Pump Set ft Standing Water Level ft <br /> 1 HEREBY ERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JO1U U ORDINANCip,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CE A E W E AUFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> W CO P NSATIO WS. <br /> IN UiRED F INSPICTTIO�N y-PLEASE CALL(20 )953-7697 <br /> DATE <br /> i <br /> Al <br /> PArkeNT <br /> tl� <br /> 052018 <br /> RpNm 01JN7Y <br /> AIZAL <br /> 0SPAR M NT <br /> F <br /> DEPARTMENT USE ONLY <br /> Applicatlon Accepted By r v' Date �w I Area `-�1 L� ! Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring inspection By Oata Con oted Well Depth It <br /> COMMENTS 17�n ,-k r4 1( C>V drilD f� <br /> PE Sc Received Ch Amount �PermlV <br /> Codes Into By Remitted Date ServlceRequest# Invoice# Well ID# <br /> 43+1 -0M()- f�-� 1511 1 sol :�5?- <br /> EHO a3-08 WELL/PUMP PERMIT <br /> 4x"12 <br />