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Tnl (A 5uvl 1 -xAl V)51 P / <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSQ--? CITY/ZIP S ��'k� � <br /> CROSS STREET <br /> C A��D I L.P 1�A APN 183-020-13 PARCEL SIZE �` O a LAND USE APPLICATION# 9 <br /> �7 pJ <br /> OWNER NAME £ - P/HONE/ I qD-�L..�'2,G' <br /> OWNER ADDRESS CITY/STATERIP ��'9CL1LD✓� p <br /> CONTRACTOR /�j/�'n��0 L�✓��/(�J� U 4 5 �6 ��P7HONE <br /> CONTRACTOR ADDRESS 7 {K' � N� I�-LI CITY/STATE/ZIP // odg 41p96-&57 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE -57 rl C-61 rl D-09 ❑ Othef NUMBER EXPIRATION DATE 7��7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range_ Section_ <br /> INTENDED USE bomestic/Pdvate n Irrigatlon/Agricultural ❑ Industrial O Water Quality Monitoring 0 Soil Sampling/Characterization <br /> ❑ Ublic Water System <br /> If different from Omer: star System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well k-Replacement Well 0 Well Alteration/Modification ❑ Other wrim <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) a of bodngs D Geotechnical M% b <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-ConnectionRepair MqR 0 3 <br /> n New Pum o Pum Replacement ❑ Pum Repair 11 Raise Well Casin <br /> WELL CONSTRUCTION SAN <br /> NVmr)JOAQUIN COU <br /> Dri <br /> ling <br /> otary 11 <br /> ry 11 <br /> r C1 <br /> le Tool <br /> her <br /> NTY <br /> Proposed deWelid Deptly-,ROkir Rot ExcavationUge��`bin diameter Ll Push❑ OpentBottom OtGravel PacWGrave SIEdiameter <br /> 12 Conductor Casing in diameter / Conductor Casing Depth k <br /> Well Casing Diameter(09— in Thickness/Gauge/ASTM Schad U Steel Plastic C Stainless Steel ❑ Other <br /> Grout Seal Depth 1099 ft tl Neat Cement(94 lb bag/5.10 gal water) ❑ Sand Cement—sack mix/7 gal water <br /> X-Bentonite(20%solids) Il Other <br /> Grout Placement Method >413umped D Free Fall [I Other U Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Xump Contractor D Other <br /> Concrete Pedestal.Dime sions:Width It Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible Turbine U Other HP Pump Set it Standing Water Level k <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR A�ANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> '` n <br /> SIGNED Y 1 G Y f'` �-Li� TITLE IJHL /.PN DATE <br /> Hill <br /> jffl <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 331/? Area Employee ID#�SCOtY9 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth N <br /> COMMENTS C'7£+O rttw6/ 4 L GOL t f:704#11 6+r—i 1E4.4J:iEc77W6-, Lt/If',Ed D/J Co,� r� <br /> tum <br /> PESC Received Ch Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> f3q o 1 Sro &19 &3oS� -13W. 3a/7 �-, D67k W7 7 <br /> �t341 3 I45.c 3 3 1 <br /> EHD 4306 WELL/PUMP PERMIT <br />