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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 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 /> !16 �� LAw Rencc ti[ Clry/LP C/¢ r 983 Z <br /> JOB ADDRESS m <br /> _ n <br /> •� p q �/�/ 3 <br /> CROSS STREET 0 <br /> APN ;( / �/O 7 7 PARCEL SIZE i ,G LAND USE APPLICATION# <br /> r1 �} m <br /> OWNER NAME K /♦ I PHONE 3 JC7 <br /> 9 vi <br /> OWNER ADDRESSL_-1 "„ `QL(J tri•« L C ?'&tCITYISTATE/ZIP ^SSC/Q/ B!tl, `j4 9f,J <br /> CONTRACTOR llell ,to G. PHONE L,I F_s / '_7 2— <br /> CONTRACTOR ADDRESS 3008 CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACT-ORR/ADDRESS CIN EIZIP <br /> /STAT <br /> LICENSE 67 _!C-61 l i D-09 - Other NUMBER EXPIRATION DATE S"-31 ./5 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Rangg Section_ <br /> INTENDED USE Domestic/Private ] Irrigation/Agricultur us 'a :p Water Q lily nitodng ❑Sal Sampling/Characterization <br /> U Public WaterSystem <br /> If different from Owner wavr ys ea I V L 0 0 GBIitac(Warr1earFFh0n9N.M1w <br /> TYPE OF WORK New Weil �0<eplacement Well L:W*i Pa 3ljgp¢vt 'I� b1 r.{�OttyxnlrV t„/,}rl�1. I <br /> n Monitoring Well(s) #Of Wells Soil B (:y71`l YbWnQr rJTf�Geotechnical t7 of borings <br /> Out-Of-Service Well Qut-01,8 ������jy��Ije v �( ji't°Git1 Di1 �� <br /> New Pum Pum Replacement C Pum lk� 1 t�Up I G Raise Wel asi <br /> WELL CONSTRUCTION !r �tl(' n�.-R <br /> r}v E:n�.rprjM, .:l IIa ,,,.!u'. LA <br /> Drilling Method 0"Mud R,'3ry 1.Air Rotary .Auger a Cable Tool J Push Point a Other <br /> Proposed Well Depth_nDC7 ft Excavation 12c&in diameter C Open Bottom `r-Gravel Pack/Gravel Size in diameter <br /> I_i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter �In Thickness/Gauge/ASTM Sched 2 6, ❑Steel '4-Plastic C Stainless Steel G Other <br /> Gr°iir Seal nepth ._).�J.., t: ^Neat Cement(941b ba iv yci wate�rj Sand Cement sack mlw7 gal water <br /> �;,pentonite(20%"solids) Other <br /> (Grout Placement Method :--,011umped ❑Free Fall ❑Other 'I Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller C Pump Contractor Other <br /> i i Concrete Pedestal L Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP I Submersible,.Turbine ,i Other HP Pump Set ft 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 A ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS MPENSAT10N LAWS. <br /> !A (MUM OU veunG un•r1rE RE^.'"DOD FOR INSPECT IONS/-/J�PlLc SE CALL(rt?�3)9c�5s-76 7 � � C <br /> SIGNED TITLE E.f'W NI Y/� //J S DATE ( • /9' / rt--) Oa <br /> •� <br /> C:)- 7_ <br /> 3" C C� <br /> OAr co <br /> CIO <br /> _ Q. <br /> � � c <br /> �. <br /> c <br /> lie <br /> o <br /> DEPA`tTMENT LLj <br /> USE ONLY <br /> Application Accepted By Date ' l 23� t Area Employee ID# u-f�o� J <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date <br /> COMMENTS V('- L,r t Constructed Well Depth ft <br /> �14t'” sy -.r •✓� �(o Z- r..-ch 1'>LlSEw WLK �L S4-c,`r�.j wLl,t,� <br /> I It <br /> Pc I SC Received Amount Pe it/ <br /> Codes Info B Date Cash Remitted Service Re uest# Invoice# WeIIID# <br /> EHD 43-00 n n <br /> 4130/12Dv �� �2 ir�. WELL/PUMP PERMIT <br /> / ,e{ <br />