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OCIT% 'lZ;Q� 1,n4iK\ 5(a, 10 -)-P, l6 ll <br /> ' WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �l li A CL'`�'� ��C j2-,�• CrTy21v �il/�'1 r�(} I Cj 5 ")�c m <br /> n <br /> 1� �• /'►t /� o <br /> CROSS STREET ,%. '�._7 Mt�.�t'S �APN(d�Z10-7V PARCEL SIZE 10L.U.I.APPLICATION# m <br /> /"' \ 1 T <br /> OWNER NAME '. �> 1 l L'�1� �'A l-ki C`� ',-C Y) a-T-n L PHONE JJ ✓1 ' 7 y <br /> OWNER ADDRESS I •{lT L.1�'\�► 1 Ir^ I\ I J �' `cnvsTATERIP �:`jc� r �'A r'�7�l/ <br /> CONTRACTOR f `, IBJ t` 1 1 1 r PHONE 763/� - -9-7 r/ q <br /> CONTRACTOR ADDRESS r. Z ) (, <" Cmr/STATE17JP `-�r.1 1 I Cly <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEMP <br /> LICENSE /�G-57 �;-C-61 Li D-09 .. Other NUMBER �CI L1- ��_i EXPIRATION DATE I -� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE ){Domestic/Private D Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Charactenzation <br /> Public Water System <br /> If different from Owner yf nnNa— o ame or a um <br /> TYPE OF WORK A New Well . Replacement Weil _Well AlteratioNModification Other <br /> .;MonitoringWell(s) *of wells SoilBoring(s) %ofWrings Geotechnical s°roonrgs <br /> Out-0f-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement _Pump Repair -Raise Well Casing <br /> WELL CONSTRUCTON <br /> Drilling Method Mud Rotary Air Rotary Auger - Cable Tool Push Point . Other <br /> Proposed Well Depth �(>�? ft Excavation I 1 in diameter "Open Bottom Gravel Pack/Gravel Size i in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_L in Thickness/Gauge/ASTM Schad C 14, __Steel 1-< _Stainless Steel Other <br /> Grout Seal Depth �,c ft Neat Cement(94 fb bag/5-10 gai water) xSand Cement ?;, sack mixf7 gal water <br /> Bentonite(20%solids) _Other <br /> Grout Placement Method_Y Pumped .Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By -, Driller Pump Contractor Other <br /> t.Concrete Pedestal -Dimensions:Width It Length ft Thick in "-Christy Box Stove Pipe <br /> PUMP ,{.Submersible Turbine Other HP Pump Set ft Standing Water Level = h <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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNEDa! /,/CL JL✓.i:� TITLE \! I t l 1�C 1 i�.� P r� DATE <br /> W� <br /> 1 <br /> DE ARTMENT USE ONLYAI t0l Al L <br /> Application Accepted /. Date At" Employee IDM [ <br /> Grout Inspectio _ !� Date // I SPECIAL Well Permit <br /> Pump Inspection By Data WAIVER Received <br /> Soil Boling Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permu#itl Invoice, Well ID# <br /> Codes Info Cash Remitted Service Re uestfl <br /> t1 0110 2:7/1V SI,007 tp I 1• <br /> os� o.° <br /> 1-901, <br /> Out 414L� <br /> 7U11 <br /> O/►y <br /> 4r"12 I WELL MU°' 727 ',r (/•��Q /' I p /Z <br /> / TIT <br /> Z <br />