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WELL/PUMP PERMIT <br /> SAN JOArIUIN COUNTY ENORONIAENTAL HEALTH DEPARTMENT 1868 EASTHAZELTON AVENUE-STOCKTON CA 96206-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 9 YEAR FROM DATE ISSUED <br /> Joe ADDRESS �•' (�A� CIiY21P <br /> CROSS STREET J�1�G�I�`1J TT 1,(i ))i 519APN ` �O PARCELSIZE `'1 LAND <br /> USE APPLICATION <br /> OWNER HANE 1_ PHONE l I <br /> OWNER ADDRESS FI rl 1..)L IG rl CITYISTATEIZIP 4'41) <br /> CnNTRACTORI hl PHONE 2 0 ef c(-(P CC)(.l <br /> CONTRACTOR ADDRESS //✓?l) -� (f';tl:.,\)i C-.'•� <br /> Ct- <br /> r -^� ( ITYISTATEIZIP <br /> SUBCONTRACTOR t/ {�lJ 1 ,-r 1?�I(i%[1-•� i PHONE 2(.) l('i' 77c!(% <br /> SUBCONTRACTOR ADDRESS .SPO(- ?J-rE`� CrI/'1-:.lL I CITYISTATEIZIP ,/;�%���"TCS:tl Cj-+•. rf:5115- <br /> LICENSE D C-57 D C-61 7 D-09 =OtherA-1 r 4 NuMDER E)(PDTATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section_ - f <br /> INTENDFD USE _DOMStic/Private ]IrtlgallonlAgrlcullural ;ndusldal D Water Quality Monitoring O Soil Sampling/Characterization <br /> -Pubfc Water System <br /> 116II4IOIIl Imm Uvner. a 4z y am xnw on ecN.M.or a S­¢r <br /> CD n!- <br /> TYPE OF WaRK New Wall =Replacement Web D WDII Nlerelion)Vodiflcalion (1011 <br /> er(-r 1.'.Ot,tni1') <br /> _MGdIodnpW8ll(s) #of wells USol[Boring(s) eetbalree UGeolechnlcal NofDarlr�e <br /> =Ovt•Of-SerNce Well O Out-Of-Service Well Renev+al i3Cmns-Coi)r=Kon Repalr <br /> -New Pum -Pump Replacement n Pump Re air n Raise Well CasingCID <br /> � V <br /> WELL CONSTRUCTION = 9 C <br /> ►� <br /> Drilling Method -Mud Rotary )eAir Rotary y'Auger D Cable Tool rl Push Point t• Other py 7a CDProposed Well Depth •77 it F-ccavaGon r, In diameter D Open Bolcom :1m <br /> Graval Pack/Gravel Size In diaeter C <br /> -Conductor Casing In diameter / Conductor Casing Depth flN <br /> _. <br /> Well Casing Diameter _In ThlcknesslGauge/ASTM Sched 7 Sleel D Plastic O Slalniess Steel n OUIer <,U �_ •v�., <br /> _ a <br /> Grout Seal DepthCIL <br /> It L Neat Cement(941b bag/5-10 gal water) U Sand Cement sack mix"gal water �+ � erslpe : <br /> enlonite(20%solids) O Other <br /> Grout Placeme t Method U Pumped D Free Fall D Other ]Retardant/Accelerator(name) <br /> ca <br /> PEDESTAL Installed By L Drillor U Pump Contractor 0111ar =.-(5 <br /> -Concrete Pedestal'Dlmensiona;Width_it Length fl Thickto ')VChrlelyBox DSlovePipe 9 <br /> PUTAP =SUbmarslbleE Turbine D Other lip PumpSel It Standing WaterLevzl <br /> I HEREBY CERTIFY T I HAVE PREPARED THIS APPLICATION AND THAT TIIE WORK WILL BE DONE IN ACCORDANCE WITH SAN Q <br /> JOAQUIN COUNTY OR NANCES;STAT6,LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE 19 <br /> CURRENT AND ACTIVE WITH THE CALIF)DRNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS cbrdPENSATION LAWS. <br /> jM 2 VOUIR ADVANCE NOTICE REQUIRED FQ `INS E TiOf1 LEASE CALL(209) <br /> T3-777 <br /> STONE . i TITLE lI�� � DATE <br /> PE ptzl <br /> N\-\ <br /> � . <br /> r`orkb - - , ,0T-H W+�-�4 <br /> �0o��PP� <br /> DEPARTMENT USE ONLY <br /> i 1 � I <br /> Appllcallon Accepted By' "- Dale t 1 I� Area c'' I i"1 Employee ID9 <br /> Grout Inspection By Dale t C SPECIAL Well Permit <br /> Pump Inspection By Date n WAIVER Received <br /> Soil Boring Inspecllnn By Data Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedhecktN, Amount Dale Parmitl InvolceR WeIIIDN <br /> Codes Into B s Remitted ServlcsRe uestll <br /> EHO 1){16 WRL 1PUMR PERMIT <br /> 4naI2 <br />