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J <br />Wt WELL/PUMP PERMIT <br />AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT boo EAST MAIN STREET-STOCKTON CA 95202 - (209) 468.3420 <br />Wrkl-KEFUNDABLE PERMIT GALL IZUW 953-7597 FOR INSPECTIONS r1A1`1Kt1, 7 YEAR FROM LIATE ISSUED <br />JOB ADDRESS h' . <5 _ CITY21P I{AL <br />Zew <br />CROSS STREET / APN fl�y!I'-' PARCEL SIZEI-Z&D USE APPLICATION # r <br />OWNER NAME 1 4r PHONEJ J / <br />OWNER ADDRESS _ _ �(!/ OO 9 r j�tiOy CITY/STATE/ZIP Zy�/%�/�-3'4 <br />CONTRACTOR ADDRESS CITYISTATE721P <br />f <br />SUBCONTRACTOR )` !/ PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATEIZIP / <br />LICENSE C-57 61 ❑ D-09 0 Other NUMBER �`� /U FIMIRATION DATE <br />GEOGRAPHICALINFORMA 014: Coordinates X Y T.—hi. Rannn Q -tl— <br />INTENDED USE D Domestic(Privaterdgation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water Sys m <br />If dlfrererA from Owner. Water Sywem Name U00ad NaMe Or MMO NUMber <br />TYPE OF WORK O New Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br />D Monitoring Well(s) # of wells ❑ Soil Boring(s) " "`"" ❑ Geotechnical <br />D Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cress -Connection Repair <br />0 New PumpPump Rolaoement 0 Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method tf Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point 0 Other <br />Proposed Well /&pth _Asa ft Excavation oe�e_in diameter ❑ Open Bottom)ravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor -� <br />r Cas�ing Depth ft <br />Well Casing Diameter/0—In Thickness/Gauge/ASTM Sched-6L �/ D Steel [XPlastic 0 Stainless Steel ❑ Other <br />Grout Seal Depth ft n Neat Cement (94 /b bagl5-10 gal water) �❑ `Sand Cement sack mix17 gal water <br />/15entonite (20% solids) 0 Other <br />Grout Placement Method 2KPumped 0 Free Fall ❑ Other 0 Retardant/ Accelerator (name) <br />PEDESTAL Installed By ❑ Driller XPump Contractor ❑ Other <br />❑ Concrete Pedestal Di rasions: Width ft Length it Thick in ❑ Christy Boz 0 Stove Pipe <br />PUMP ubmersible❑ Turbine 0 Other. HP Pump Set ft Standing Water Level ft <br />1 HEREBY CE IFP 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTH WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />JMIN U OUR ADVANCE NOTICE PEPUIRE <br />9FO INSPECTIONS n <br />SMEjVY// f �/'L_ TITLE s'^J/ liK�'Y �--- DATE A <br />0� -- <br />Application Accepted <br />Grout Inspection <br />Pumpinspecti <br />'7` <br />Soll Boring Inspection 6y� <br />mom <br />�4 MENT U E NLY <br />Date /O Or� Area ©D� /7 Employee ID# <br />Date / ❑ SPECIAL Well Pertllit <br />DateZ61 <br />nz ❑ WAIVER Received <br />_ Date Constructed Well Depth it <br />s sils� <br />•ilii-�.."Yt+� !O ��2Ya'�'�-• ,d2ldL1� <br />N <br />m <br />D <br />PE SC <br />odes Info <br />Received Check#/ Amount Date <br />_ B Remitted <br />Pe It' <br />Invoice # Well ID# <br />Service R uest N <br />�y <br />3� 3 'ba <br />OSSA <br />[d pva9 5�i/ <br />EHO4306 .d"W/4-K—': r/ IL, "KJ- d •,•• C4 P— i�Lyyc %` !- "t//- !G<��.•"�••.•• yid��l/�� 'Ci' -C`-= AYiG-` LIPUMP PER <br />8/04/00 <br />