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�1 <br /> / WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY NVIRON E AL"^ 'HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-.STOCKTON CA 98206-(209)488-3420 <br /> NON-REFUNDABLE PERMIT Iv CALL 209 953-7697 FORINSPECTIONS <br /> I EXPIRES 1 YEAR FROM DATE ISSUED <br /> 10 <br /> JOB ADDRESS r'1'•l� ()G S 1 � �. +' CirvfLP V L, l 9 5 9 t V ig <br /> CROSs STREET 1401 la Ni!I CAC APN t 5�•1.�U `� PARCEL SIZL I.7 (0 LAND USE APPLICATIONS _- <br /> OWNER NAME _ tA.,-'{',.r-�•' ('I,-i'[.V"�,..L- •��1,�i,.r PHONE r•�7 N <br /> OWNERADDREs3 W y�, t J(�lt�j ` r � rt. CITY/STATEOP �`^J1 I C �17L�140 <br /> CONTRACTOR Y I (moi) 1�C 1 I`,ldT) 7�2.1.(' PHONE -7/'.h,-1/� �( 7J 1 <br /> CONTRACTOR ADDRESS •C X 1 CITY/STATEILP G i i�f (A 9 50 3 D <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/71P <br /> LrceME 67 X,C-61 U D-W I-Other NuMaER C 3 f 11 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range Section_ <br /> INTENDED USE D DomesUdPrtvate^t JrTlgaHan/Agdcuhural - Industrial ❑Water Quality Monitoring D Soil Sampling/Characterization <br /> r:Public Water System <br /> I(dl0wv4 Som Ownw: ar y.-m Mme e"of Front munum <br /> TYPE OF WGRK New Well ❑Replacement Well C Well Alteralion/Modflication G Other <br /> n Monitoring Well(s) #of wells C Soli Boring(s) a of hodngs ❑Geotechnlcal a of boring <br /> n Out-Of-Service Well r Out-Of-Service Well Renewal n Cross-Connection Repair <br /> ,e-New Pump ❑Pump Replacement C Pump Repair n Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method)OWRotiry n Air Rotary r Auger 1 Cable Tool I Push Point r1 Other <br /> Prop.s.d We11 Depth 0_ft Excavation 1-4_in diameter r Open Bottom ',Gravel Pack/Gravel Sizer In diameter <br /> I7 Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched K YA ❑Steel >(Plaslic "Stainless Steel ❑Other <br /> Grout Seal Depth F R n Neat Cement(94/b beg15-10 gal water) II. Sand Cement lio.; Sack m1xr7 gal water <br /> U Bentonite(20%solids) u Other <br /> Grout Placement Method Pumped LI Free Fa11 U Other u Retardant/Accelerator(name) <br /> Installed Sy .Driller U Pump Contractor, U Other <br /> oncrate Pedeatsl"Dimensions:Width 7 ft Length ft Thick in n Christy Box n Stove Pipe <br /> he Submersible-Turbine n Other HP Pump Set_JL,-) it Standing Water LevelLI It (�51 <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 /> MINIMIJIVI 24 HO �A�DDVnA�N^CE NOTICE REQUIRED FO\R,INSPECtTION$-PLEASE CALL(209)953-7697 <br /> SIGNED r'L f-E �-'v�V"�cA�• TITLE V•� �' 1 'J• DATE r J <br /> I r W- 322 L <br /> - � - ,c,-.� � ".i 370-- Vis" •tel <br /> IV <br /> - c <br /> /) l•�:�.- iii <br /> cZL <br /> l6%1 fir. rt <br /> I <br /> DEPARTMENT US ONLY ri'`'S :�} <br /> Application Accepted By <br /> Date; 5 Area l z2( Employee IDS <br /> 1 J <br /> 7 !! (.,u <br /> Grout Inspection f Date: 221-, ❑ SPECIAL Well Permit <br /> Pump Inspect n B�a _F - Date �� �a EI WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth _��! �{'� <br /> COMMENTS V V <br /> PE NA <br /> SC Received eckiN Amount Permit! <br /> Date Well <br /> Codas Info BY Remitted Service Request Invoice#est# rj g, <br /> 333 <br /> END 43-09 WELL"pump PERM <br /> 4130[12 w� <br />