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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 <br />NVN-R1::FUNUAE1LE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br />JoeADDRESS 1 ' Ss j'k'(nyn /� ! n % r�J/�� CITY1ZIPA.CJ1 Gs� Zo <br />CROSS STREET �•'�y�_� j 1 , APN Q Z� D�V �9 / PARCEL �jQE („AND USE APPLICAT/IIOONN # <br />OWNER NAME .j..5[.rr(r' Or�tZ �- •• �' PNON���1"II'y�s <br />OWNER ADDRESS `I Y7> "W a gA CITY/STATEIZIP �CA Tttt�7 <br />CONTRACTOR - —V oAcK PHONE <br />CONTRACTOR ADDRESS 25 9b N--w6r Jic 9A CITYISTATEiZIP - n rA- gS215- <br />CITYISTATE/7IP <br />C-57 ❑ C-61 D D-09 D Other <br />EXPIRATION DATE <br />rnruRwwr run: a uurulnares e Y Township Ranne S— -- <br />NTENDED USE )§ DOmeStiC/Private D Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />D Public Water System <br />It different from 0xner. Water Symern Narne o ama or re um <br />u ivcry vvcn u neplacenlern wen U Well AReratlon/Morimcatlon 0 Other <br />❑ Monitoring Well(s) #of wells n Soil Barings) Aor boings 0 Geotechnical uofborings <br />_0 Out -Of -Service Well u Out -Of -Service Well Renewal D Cross -Connection Repair <br />0 New Pump D Pump Replacement 0 Pum Repair D Raise Well Casino <br />Drilling Method D Mud Rotary D Air Rotary D Auger 0 Cable Tool 0 Push Point D Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom D Gravel Pack/Gravel Size in diameter <br />n Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter—in ThicknesslGauge/ASTM Sched D Steel D Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth 11 D Neat Cement (94 Ib 11aV5-10 gal water) D Send Cement sack mixt7 gal water <br />❑ Bentonite (20% solids) D Other <br />Grout Placement Method 0 Pumped 0 Free Fall ❑ Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller D Pump Contractor ❑ Other <br />D Concrete Pedet;W Dimensions: Width It Length ft Thick in 0 Christy Box 0 Stove Pipe <br />PUMP $ Submersible❑ Turbine ❑ Other HP— Pump Set r ft Standing Water Level ft <br />I HEREBY CERTI I HAVE PREPARED THIS APPLICATION AND THAT THE WORT{ WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUN RD CES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND PkCT TH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COM ENS O LAWS, <br />MINIMUM 24 HOUR ADVANCE NOTIt Qt¢IkED FOR INSPECTIONS r <br />SIGNED „TITLE `�r�T1i�y` /-? 'L` <br />DA <br />'Application HcceptedB` <br />�• -Purnpinspection <br />sou.uonng4nspecti-n <br />COMMENTS"r. <br />� •` �G'�7G�L�ir�' <br />PE <br />N <br />4Ay <br />A <br />M <br />N <br />PA TMENT U E ONLY J ` <br />_�-Area- -^ �- - �""'� ETpCj�.-ID Date ❑ SPECIALNI2lI Peit <br />Date cD �❑ WAIVER Received. _ <br />Date Constructed-Well..Depth. - "-ft•'�^"'-"-' <br />f4.Y/ ! /�iav✓ 11A-., n ��ir»aii inn f <br />SC Received Ctfeck#1. <br />Codes info I- B <br />-Amount � :. tea- -� Permff! •• — <br />emitted Service Request # invoice <br />enu na.Uo g <br />Irraaoe <br />r <br />I.. <br />WELL /PUMP PERMIT.+may <br />