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WELL/PUMP 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 <br /> MEXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1110 �� pl,,�r Q-, N � K_ I/3o� 00 F'V,V�I CITYILV 1 I[a TV v-. �s�3t gD <br /> CROSS STREET '^V�� -1�Oi Ot�� `-d AR a_ x-73 _PARCEL SSE `;? •_LAND USE APPLK:ATION S m <br /> OWNER NAME `" �N A�,�OY'N��(� 1 RLC, nPHONE <br /> E/L <br /> OWNER ADDRESS �0 " • 1.S D� �1• O CITYISTATP ,FOSQ-V l'I` Co . 95 <br /> ybp <br /> CONTRACTOR a l w � �' M PHONE D-07 <br /> O 9- 6 - <br /> CONTRACTOR ADDRESS s- f 2 CITYISTATE/ZIP 1 V f 1 O,h.. .r.. 1 5 3" <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRE83 CITY/STATPJAP <br /> LIcENSE VC-57 C-61 D-W Other NUMBER 3`4 EXPIRATION DATE 5 -31 -a3 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE Donleshr/Phvate rrigation/Agricultural Industrial Water Quality Monitonng _ Soil Sampling/Characterization <br /> I <br /> Public Water System <br /> If aiTarenl I—Omer Water ys.em a LOMaCl Nam or PbCre Nuriber <br /> TYPE OF WORK k4w Well Replacement Well Well AlterationiModificetion Other <br /> Monitoring Well(s) X of wells Sod Bonng(s) a of bones - Geotechnical a of t'o­gs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> J New Pum - Pump Replacers t _ Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tod { Push PWM Other <br /> Proposed Well Depth a•Da ft Excavation �Qi- in diameter - Open Bottom V�ravel Pack/Gravel Sizes_in diameter <br /> Conductor Casing to diameter / Conductor Casing Depth ft <br /> Well Casing Diameter I�k-in Thickness/Gauge/ASTM Sched _ Steel mastic - Stainless Steel Other <br /> Grout Seal Depth S Q it - Neat Cement(94 to Dag/5.10 gel water) V'Sbnd Cement I O• sack nv/R gal water <br /> Bentonite(`/20%solids) Other <br /> Grout Placement Method YTumped Free Fall - Other Retardant/Accelerator mame) <br /> PEDESTAL Installed By Driller camp Contractor Other <br /> Concrete Pedestal_.Dimensions.Width ft Length ft Thick in _Christy Boa _ Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level R <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 /> MINIII�liM�2M OU ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED Q�� TITLE DATE <br /> RF y�F <br /> � Oc �FjV�,6T <br /> T <br /> FF I <br /> 8 <br /> OFA FN��Nry <br /> NT <br /> DEPARTMENT USE QNLY <br /> Application Accepted By CSL L Data r��''�F �/�y� Area I"�t'�""Employee IDB <br /> Grout Inspection By ale !l./7 w vt :1 SPECIAL Well Permit <br /> Pump Inspection By Date :1 WNVER Received <br /> Soil Boring Inspection qy D eConstructed Bit Depth R. <br /> COMMENTS o� F' '^ll i ' , SO, f't I Ht C C r. IK 6-G f <br /> PE SC Received CheckB/ Amount Dats P Invoice u Well IDrf L <br /> Codes Into h Remitted Mce uast Y <br /> 14, <br /> J�(J' WEi'.HUMP PERMIT <br /> EHD N7-OO ^� <br /> oaa, <br /> 13 C/ <br /> 3 34575 <br />