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NVELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL. 209 953-7697 FOR INSPECTIONS EXPIRES i YEAR FROM DATE ISSUED <br /> wU�Iq I� x Rd `S�ycfi� �52�5 <br /> JOB ADDRESS Cm'/ZIP <br /> M J�/J/ �f 7 Z c( 0 <br /> CROSS STREET f-I /f-/L��� APN 13S U�`�_JS PARCEL SI7E LAND USE APPLICATION 1J <br /> OWNERNAME G PHONE 20q-CO <br /> G�a616 <br /> OWNERADDRESS l�tJ�;y� CITY/STATE/ZIP`� 1 I�. l J2AS <br /> CONTRACTORf I � r ISS /�`{'�l p� ���"'r-p �lJ PHONE 2M-:131-3zrf O <br /> CONTRACTOR ADD2 <br /> RESS K`/ I�U1�t.Cl�j 777CITY/S1'ATFlZ1P liq <br /> �L`. ]_ <br /> SUBCONTRACTOR E ( f PHONE N <br /> SUBCONTRACTO ADDRESS !/T CITY/STATE[ZIP C <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICALMILMATION: Coordinates X Y Township Range_ Section I�. <br /> INTENDED USEDomestidPrivate C]Irrigation/Agricultural 11 Industrial ❑Water Quality Monitoring 13 Soil Sampling/Cbaracterization <br /> blic Water System <br /> Irdltraentrmm Owner: W.k, ynem amsCo.-, .mew Phm. um r <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration,Modification ❑Other I(�� <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #.fb.p°p ❑Geotechnical s orborinas ,\ <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> Pum R Iacement ❑Pump Repair (\ <br /> WELLCONSTRLCTIQN �1 <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Kell Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge)ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other rC <br /> Grout Sed Depth ft ❑Neat Cement(941b bag/3-10 gal water) ❑Sand Cement sack miz/7 gal water `.• <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted CI <br /> Trout Placemeat Method ❑Pumped ❑Fra Fall ❑Otner ❑Retardant/Accelerator(name) IO <br /> PEUSTA Installed 6y ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length n Thick in ❑Christy Box ❑Stave Pipe <br /> PC.Mt Submersible ❑Turbine ❑Other HP Pump Set19�ft Standing Water Level ft <br /> 1 HEREBY CERTIFY'THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN y <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 /> NI Nl NI 24 HOUR ADVANCE NOTICK REQUI ED FOR INSPECTIONS / <br /> SIGNED TTIT.E DATE l _ <br /> cA <br /> D A Th1ENT_ US F ON � <br /> Application Accepted By 20te Z Area Employee 1D# ` /7f, <br /> 7 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date /Q/L C O G ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS E1k62�41-�„/ StccO O� !a�<��<'• Sfxw�l�r :ft,-p 6k /2 C2 in <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well IDX <br /> Codes Info B Remitted Ser.ice R nest# <br /> oSZ� coo 3`13 <br /> eHD+M.011G W ELL PUMP PERMIT <br />