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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HaALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209 8420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �`�` finn�}} h <br /> JOS ADDRESS 1 by) , LP&,,,b4- Tr-c>r✓ CITY/ZIP y^ OVf <br /> m <br /> F�IVA 19, APN D$ — °o <br /> CROSS STREET e 1 1�b'^ �UPARCEL S r T LAND USE APPLICATION# R <br /> OWNER NAME {/(/ LL PHONE. -/-/ /' <br /> OWNER ADDRESS 8. 17 CnV1$TATEfZIP V� l✓-�'DY`. <br /> CONTRACTOR �i fit, ^ nP�HONE11?P j- 116- aD�g <br /> CONTRACTOR Amuse 3-03 r ! i�lh cY�I/I CITY/STATE21P <br /> SUBCONTRACTOR Y- PHONE <br /> SUBCONTRACTOR ADDRESS ✓ -;CITY/S/T�ATE/ZIP C <br /> LICENSE C-57 (IC-61 ❑D-09 ❑Other NUMBER-' EXPIRATION DATE ✓ I—Z-0111 <br /> GEOGRAPHICAL INFORMATION: Coordinates X -R Y — �. Township_ Range Section <br /> INTENDED USE ❑DOMOSUC/PriVate A <br /> Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soti Sampling/Characterizatlon <br /> ❑Public Water System <br /> If different from - YVatOrbyVeMNarne o ams or one um er <br /> TYPE OF WORK eW Well ❑Replacement Well ❑Well AReration/Modification ❑Other <br /> ❑Mortltoring Well(S)_,-,_,,,,-#of wells D Sol,Boring(s) #of borings ❑Geotechnical #or borings <br /> O Ut-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connectlon Repair Q <br /> New Pump ❑Pum Replacement ❑Pump Repair (� <br /> ELLNSTR d Tb !(� <br /> Drilling Method 0 Mud Ro ry ❑Air Rotary ❑Auger Cable Tod ❑Push Point ❑ Other G l� <br /> Proposed Well Depth ft Excavation \ in diameter Open Bottom D Gravel Pack/Gravel Size in diameter <br /> ❑Conductor sing In diameter / Conductor Casing Iftth it <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth <br /> It 0 Neat Cement(94/b 10 gal caste() p1lQfand Cement sack•mIV7 gal Water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Metho Pumped 0 Free Fall ❑Other ❑Retardant/Accelerator(name)__- <br /> PEDESTAL Installed By Driller- ❑Pump Contractor ❑ Other <br /> ❑Concrete Pads—j Dimensions:Width ft Lengthft Thick In ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submerslbt Turbine D Other.. _ __ HP Pump Se ft Standing Water Level h <br /> 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNE4 r <br /> —c--� TITLE �_ _ _— —- DATE <br /> A <br /> IN <br /> O M <br /> T <br /> WETMENTUE NLY <br /> Application Accept yDate Area Employee ID#*Grout Inspectiony. 41aDate �� ❑ SPECIAL Well PermitPump Inspectlo yDate �d /� ❑ WAIVER Received <br /> Sall Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS /Q <br /> PE Sc Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> 1 0twoooh. -3 <br /> 3 <br /> EHE'43-06 <br /> 9r28107 WELL/PUMP PERMIT } <br />