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/ WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY NVIRON A"�L 7HEALTH DEPARTMENT 1808 EAST HAZELToN AVENUE-STOCKTON CA 98205-(209)488-1420 <br /> NON-REFUNDABLE PERMIT ,>'v V CALL 20.1y9 963-7697 FOR <br /> INSPECTIONS EXPIRES 1 YEAR FROM <br /> /DATE ISSUED <br /> Joe ADDRESS ••��r'�" 1{���r�U�"7l 1 rc LY 1.1• CIT'ILP LLoA I i J a4o <br /> CROs STREET I-+1,J I IL) V i�%`'SD_` APN C�>, k k.2� `� PARCEL S¢!I.7 f(J LAND USE APPUCAnON# <br /> OWNER NAME _ IIAi7-2'`J-/y (i-i.'V`r"�..C- .{-�-1,J�r y/ 1 PHONE /� _ ,t <br /> OWNER ADDRESS\I� 1,� `', u 1 iJCr��Lal`i ` /l l/i',f'tr•- rG�- cmisT nop t CO, I� C/"1 ^( -5�•r�`T V <br /> CONTRACTOR V�{le'7 Dc" <br /> 1` 1 `1nn�I �,1 (1Z.Lj L-'r /-,L. 1-�-`!{-Y)4• PHONE .h' f71 //'7J �' <br /> CONTRACTOR ADDRESS P•U• 6o `(�K CITY/STATE/LP. G,,i f CA 9 S(.,J <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CfTY/STATr1ZA23 /P <br /> LICENSE 57 $i U D•09 L Othaf NUMBER C <-1 EX%RATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range Section_ <br /> INTENDED USE ❑DomesUdPrivate ,,Qrrigation/Apdcultuml 7 Industrial D Water Quality Monitoring ❑Soil Sampling/Cheracterizatlon <br /> n Public Water System <br /> If dln.nrA Nom Owns: •.,sym.. .m. U01AW NO—or .. u <br /> TYPE OF WORK New Well D Replacement Well C Well A tere11GNModificallon 0 Other <br /> II Monitoring Well(s) #of wells C Sol]Bodng(s) s of bodrVs 0 Geotechnical a of borings <br /> n Out-Of-Service Well r Out-Of-Service Well Renewal n Cross-Connection Repair <br /> -Z-New Pump ri Pump Replacement C Pump Repair O Raise Well Cash <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mud Rotary n Air Rotary f-Auger -1 Cable Tool r Push Point n Other <br /> Proposed Well Depth ?Ab R Excavation t,4_in diameter n Open Bottom '>CGmvel Pack/Gravel Size_In diameter <br /> U Conductor Casing In diameter / Conductor Casing Depth tt <br /> Well Casing Diameter r In Thickness/Gauge/ASTM Schad {c C� 0 Steel XPlastic El Stainless Steel ❑Other <br /> Grout Seal Depth -50 ft D Neat Cement(94 lb bag/5-10 Us/water) 't.Sand Cement 1(J•�i sack mlxR gal water <br /> LI Benlonite(20%solds) u Other <br /> Grout Placement Mafhod Pumped u Free Fall U Other Ll Retardant/Accelerator(name) <br /> PEDESTAL Installed By _Drlller U Pump Contractor„ U Other <br /> ?(,Concrete P�destal'Dimensions:Width 7 ft Length R Thick In n Christy Box rt Stove Pipe <br /> PUMP Submersible-Turbine n Other HP--t5 Pump -� R Standing Water Level � It 951 <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 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> `-PLEASE CALL(209)953-7697 <br /> \ <br /> SIGNED C �V"+c�1' TITLE )I(c 1�1�J, DATE - 1.� <br /> ). <br /> 41 <br /> II I <br /> v r 20- x;_ <br /> - - = e11 <br /> �- <br /> 1 <br /> V. <br /> �i 5 c5 <br /> ` l a� <br /> DEPARTMENT US ONLY /I' "'�"i' s7 <br /> d.•r L Employee ID# <br /> Application Accepted By 7 Dale'i 7 S Area <br /> Grout Inspection y Date: Ir% 0 SPECIAL Well Permit <br /> f <br /> Pumnp Inspect 8 _ ,r'• - Date // �, 0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft .10 <br /> COMMENTS .Q�`�I (�j r <br /> PE SC Received 6 eck#/ Amount Permit/ (_ <br /> }� Date Invoice III Well <br /> Codas Info B �Cae Remitted Service R est# <br /> EHD 43.06 WELL IrumP PEHhi <br /> anon: <br />