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WELL/PUMP PERMIT /gQ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(2D9 953-7697 FOR 1NSPEr.TIO\s EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS jSF � yQ,� <br /> � � CITY/ZIP <br /> CROSS STREET APN._22-�7"' Do-4•v PARCEL SIZE e ° <br /> �,j/`/��{J�� � � LAND USE APPLIG'CION# � <br /> OWNER NAME �•�L C�J VY I (',�1 t.�;"-9 <br /> Q Y �/ GZ PHONE <br /> OWNER ADDRESS ` ( ��^ �7 CM/STATE/ZIP�14 Gam.-�aL C'�f <br /> (CONTRACTOR 1e76L ell,s PL�A <br /> II (% ��{t {/��, PHONE <br /> CONTRACTOR ADDRESS 1 1 n//.6,- K CITY/STATE/ZIP -PS <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP �.�f�'7 <br /> LICENSE C-57 ❑C-61 C1D-49 ❑Othcr NUMBER -Z EXPIRATION DATF,2L/'G f <br /> GEoGRAPHICAL1NFORMATION.- Coordinates X V Township_ Range Section_ <br /> INTENDED UsE mestic/Pnvate ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitonng ❑Soil Sampling/Charaeterization <br /> ❑Public Water System <br /> Ifdiffercnrfm.Own.: ate, yrt.n.arae ontact M1ame or none um r <br /> TYPE OF WORK ow WeN ❑Replacement Well ❑W41 Alteration/Modification ❑Other <br /> ❑Monitonng Well(s)_#of wells ❑Soil Boring(s) k of bonnga ❑Geotechnical x oFbodngs <br /> ❑Out-Of-Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> 1 WELL Coss rR UCr90N <br /> Drllli,Method t5*�Jud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter p Open Bottom Gravel Pack/Gravel Sim in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth tt <br /> Well Casing Diameter ,in Thickne.s C..g.(ASTM Sched /ll'6'7 ❑Steel Mastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(D4 lb bag/S-10gat water) D Sand Cement sack m /7 gal water <br /> 3 � ix 9 lentonite(20n/Solids) ❑Manu;acturer Spec%solids_% Name ❑Specs on File ❑Specs Sebmttted <br /> Grout Placement Method meed ❑Fra Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL. insWed By ❑Driller �ump Contractor 11 Other <br /> --- <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> pim'. ❑Submorsible ❑Turbine ❑Other HP Pump Set R Standing Water Level ft <br /> I HEREBY CERTIFY THAT I 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 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> �MINIMUM 24 HOUR ADVANCE NOTICE REQUI1•lnT.ED FOR INSPECTIONS / <br /> SIGNED_j��/L /'�(-L6yrZ G� TITLE AN,�l LE"s, DATE .�` G <br /> M <br /> T � <br /> 11 10A <br /> EPARTMENT SE ONLY <br /> Application A ted B � <br /> PP Y Date Area Employee tD# <br /> Grout Ins tion By .,..���.�- Date �i/6?6 ❑ SPECIAL Well Permit <br /> Pump lnspecnon BY Dace ❑ WA1vER.Received <br /> Constructed.Well Depth <br /> COMMENTSPE Sc Received Check#i Amount PermiU invoice# Well SD# <br /> Codes Into B s Remitted Date Set•vlee R ueal# <br /> bb yr 3 b9 to o Lupo a o y� <br /> It <br /> I <br /> END 43.02406 <br /> V2712W WELLPUMPPERWT <br />