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WELL/PUMP PERMIT <br />Sera JnenULN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAW STREET - STOCKTON CA 95202 - (209} 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL32009 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />32 S Z S Kos- <br />a <br />Cm27tP <br />Tic c / q S 30`/ <br />JOB ADDRESS , <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib beg/S10 gal water) C Sand Cement sack mixl7 gal water <br />0 <br />71 <br />``'Ll <br />2'5s - t 00 -Z6 <br />PARCEL SIZE } 9 3 <br />3LAND USE APPLICATION # <br />CROSS STREET :H j '1 33A <br />- " <br />PN <br />PUMP q Submersible C Turbine Other HP �� Pump Set 1 2 O ft Standing Water Level 4 _ It <br />t4 \ <br />LQ Vella <br />PH0Nr����ZO-a IL1,0 <br />OWNERNAME fth 4 --CL S <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />OWNERADDRESS 1957-16 <br />CrrytSTATPJZIP <br />�✓G�14 5.312 <br />CONTRACTOR <br />PHONE <br />CONTRACTOR ADDRESS <br />CITYISTATFJZIP <br />SUBCONTRACTOR <br />. PHONE <br />SUBCONTRACTOR ADDRESS <br />CRYISTATE21P <br />LICENSE C C-57 :: C-61 E D-09 <br />C Othei NUMBER <br />EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Aec[ion <br />i LADED US R Domestic(Private D IMgation/Agricuhural U Industrial C Water Quality Monitoring �i Soil Sampling/Charactedzabon <br />Public Water System o time o um r <br />11 di fererrt from Owner: r nr arne <br />TypE OF Wow n New Well ❑ Replacement Well D Well AlteratWModificatiOn L Other <br /># of borings I-, Geote&nical x of Uorin{ry <br />= Monitoring Wells) #of wells C Sal Bodng(5) <br />n Out -Of -Service Well 6 Out -Of -Service Well Renewal a Cross -Connection Repair <br />x New Pump it Pump Replacement 0 Pump Repair Raise Well Casing <br />Drilling Method G Mud Rotary D Air Rotary D Auger D Cable Tool a Push Point n Other <br />SC <br />Info <br />Proposed Well Depth ft Excavation in diameter Ll Open Bottom L Gravel Pack/Gravel Size in diameter <br />.21 <br />N <br />J Conductor Casing in diameter / Conductor Casing Depth ft <br />LAtl <br />Well Casing Diameterin Thickness/Gauge/ASTM Sched D Steel ❑ Plastic Il Stainless Steel L Other <br />� <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib beg/S10 gal water) C Sand Cement sack mixl7 gal water <br />Bentonite (20% solids) D Other <br />-5-o. <br />Grout Placement Method J Pumped n Free FalI 0 Other Retardant i Accelerator (name) <br />0 5X0 1 i� 0� 3 3 <br />PEDESTAL Installed By '� Driller C Pump Contractor n Other <br />L Concrete Pedestal Dimensions: Width ft Length ft Thick in L; Christy Box ❑ Stove Pipe <br />PUMP q Submersible C Turbine Other HP �� Pump Set 1 2 O ft Standing Water Level 4 _ It <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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 HnOU�Ry ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95,3/-7697 <br />Crrucn VLiw Y.f115AL.JC-Y''L. - TITLE 1 DATE <br />l <br />DEPARTMENT USE ONLY <br />Application Accepted By Date 00 <br />4 Grout Inspection By Date <br />` Pump Inspection Bye �o <br />Soil Boring Inspection By Date <br />Area Employee ID# 0 (� <br />0 SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth It <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />CheckAt <br />s <br />Amount <br />Remitted <br />Date <br />PerrntU Invoice# Well 10# <br />Service Request # <br />df3� <br />0-5-0 <br />SD <br />-5-o. <br />0 5X0 1 i� 0� 3 3 <br />