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WELL/PUMP PERMIT / ^`, <br /> SAN JOAAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209yd 3420 <br /> NON-REFUNDABLE PERMIT 11 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOe ADDRESS 1�P / 0. 4P_m.6 rr.t,J/ CRvfLP y^ 1 A S"2 m <br /> X11-V,� ) � — t�J f0 <br /> CROSS STREET Q APN_D 5,_ /p)�b ptjPARCEL S 4�� D USE A�PyP{ILICATION# <br /> OWNER NAYS t� 1.L \)Xne <br /> PHONE_ <br /> OWNER ADDRESS r D CITYISTATE/ZIP V ` r C� a1a53 <br /> CONTRACTOR Kin,✓+�C/JYJD�T7�M.m p Q�J 4 QP�HONE�Dg- <br /> CONTRACTOR ADDRESS 3a 3 E /, ��h ��j1�N t A�/,144 CITYISTATEIZIP Y X11 LT, CA„ <br /> SUBCONTRACTOR <br /> PHONE A <br /> SUBCONTRACTOR ADDRESS w CITY/STATEIZIP V <br /> LICENSE C-57 D C-61- 0 D-09 ❑Other .NUMBER ExFMRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinat-es X <br /> Y - - •' .- \; <br /> --` Township_ Range Section_ <br /> INTENDED USE D DOmestic/PrIvate 't�Irdgatfon/Agricultural 0 Industrial 0 Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water S stem <br /> If difrererd from oar: er Y..m Narrm contacterre or one um er <br /> TYPE Or;WOR K�e few Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells 0 SoliBgring(s) N of borings ❑Geotechnical Norborlryp <br /> 0 ut-Of-Servlce Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair Q <br /> •New Pump ❑Pump Replacement 0 PUMP Repair <br /> WELL CONSTRu TIO <br /> Drilling Method D Mud Ro ry 0 Ar Rotary 0 Auger bie Tool 0 Push Point ❑ Other (� <br /> Proposed Well Depth it Excavation \\ In diameter Open Bottom ❑Gravel Pack/Gravel Size <br /> in diameter <br /> ❑Conductor C sing in diameter / Conductor Casing _e tth g <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched f a _ 'Steel 0 Plastic ❑Stainless Steel ❑Other <br /> Grout seat Depth It 0 Nest Cement(941b g/S90 gef water)` and Cement <br /> 0 Bentonite(20%solids) ❑Other sack-m&17 gal water <br /> GrQut Placement Metho QLpumped ❑Free Fail ❑Other ❑Retardant/.Accelerator(name) "+ <br /> PEDESTAL Installed By <Driller- 0 Pump Contractorl❑ Other (�ry <br /> ❑Concrete Pede_._)Dimensions:Width, It Length It Thick In 0 Chr1Sty Box ❑Stove Pipe <br /> ter Level V <br /> PUMP HP❑Submarsibl Turbine ❑Other. P -E <br /> t Pum Set 1�+ A ft Standing Waft f <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND <br /> JOAQUIN COUNTY ORDINANTHAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> CES, 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> TIRE.S-_ A DATE.J,,� <br /> I <br /> A UI <br /> D <br /> - T <br /> I <br /> i <br /> I <br /> DEP RTMENT U E N L Y <br /> Application Accepted Date <br /> Area Employee lD#* 11 <br /> Grout Inspection y. '` Date �V� J ❑ SPECIAL Well Permit <br /> Pump Inspectio y Date D WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE 3C Received Amount Permitl <br /> Codes <br /> into B Cash Remitted Date Service Request# Invoice# Well ID# <br /> 3Z <br /> EHD 4306 <br /> SMW W 6LL(PUMP PERMrT <br /> 1 <br />