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? � WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY EWRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 952D2 (209 46"420 <br /> NON-REFUNDABLE PERMIT/ f CALL(209)(95/3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> .JOB ADDRESS �+ � iO4n >ii L) 7/G �y&C� CITYIZIP_ f r-r-rCy'. j.%4 p <br /> L� v <br /> CROSS STREET r'ri�_ y IveAPN f•s�S' r D�rW✓ PARCEL SIZE O' w f'LANG USE APPLICATION# p <br /> OWNER NAME ..._ y S -r^l�-5'f� •'!e e- P//-e -lG f .e,.__ PHONE 6e'k /d8�/'^�y�Ze.�Fl�9 y <br /> OWNER Ap011 /Z CITYISTATEIZIP I rn �+ <br /> CONTRACTOR Ve5f..Co i 5%qn L�LE.'f+r'�t D�j/} [7�gS��v ELr^ �rrc PHONE G)4l <br /> yt�3S~ <br /> CONTRACTOR AODi P. n 9, CITYISTATEIZIP 47/--.rt , Cfj f, r/-Y <br /> r <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS -C•IITYISTTATEIIZIP <br /> LIG1iNSE C-57 C-61 IID-09 xOther J•JZ{ f" <br /> NUMBER [ 3 r 93 F EXPIRATION DATE d�/3 <br /> GEOGRAPHICAL INFOg4t0.nON: Coordinates X - Y Township__Range Section <br /> INTENDED USE Domestic/Private _I IrrigationlAgricultural Industrial j Water OualityMonitoring ,r. Soil SamplknglCharaclerizetion <br /> C Public Water System <br /> lid]Hataot from Owner. a er Ys em oma on acNa­or one um er <br /> TYPE OF WORK L New Well I:- Replacement Well 'I Well AkeralionlModification C Other <br /> I MonitoringWells #of wells r Soil Bonn s rR or borings a nl bnnogs <br /> I } 4( } Geotechnical <br /> I Out-Of-Service Well n Out-Of-Service Well Renewal I Cross-Connection Repair c� <br /> L New Pump Pump Replacement 1] Pump Repair I Raise Well Casing <br /> WELLCONsTRUcnON <br /> Drilling Method I Mud Rotary I I Air Rotary ,Auger - Cable Tool ''Push Point I Other <br /> Proposed Well Depth ft Excavation in diameter :1 Open Bottom n Gravel Pack/Gravel Size in diameter <br /> C Conductor Casing in diameter I Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness/GaugaIASTM Schetl I Steel Plastic I Stainless Steel + Other <br /> Grout Seal Depth ft r:]Neat Cement(94 fb bagl5-10 gal water) Li Sand Cement sack mix[7 gal water <br /> I. Bentonite{20%solids) !.I Other <br /> r <br /> Grout Placement Method I Pumped rI Free Fall '-!Other i Retard an]1 Accelerator(name) <br /> PEDESTAL Installed By C Driller - -I Pump Contractor I Other <br /> C Concrete Pedestal Dimensions,Width ft Length ft Thick in f Christy Bax D Stove Pipe <br /> PUMP C, Submersible Turbine y Other HP •S Pum Set d R <br /> _ P �_.--_h Standing Water Level�R <br /> i HEREBY CERTIFY THAT 1 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 /> .,;jCURRENT AND.ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE.LICENSE.BOARD AND THAT I AM IN COMPLIANCE WITH-ALL-..F <br /> WORKERS COMPENSATION LAWS, <br /> INIMUM 24 HOUR ADVANCE NOTICE R`�REQUIRE•-DFOR INSPECTIONS /l <br /> SIGNED TITLE F f1 e y G <br /> ,I C1r'! t-�eE.� DATE 45 / a 1 1 <br /> 1� <br /> �Ervr <br /> E1VED <br /> S 2010 <br /> UIN COUNTY <br /> NMENTAL <br /> ( PARTMENr <br />{ <br /> RTMENT UNLY <br /> Application Accepted ByH- 62,= Date 10 /0 Area Employee ID# ��� G( <br /> Grout Inspection By SPECIAL Well Permit <br /> Pump Inspection By Or, _ Datp WAIVER Received <br /> Soil Boring tnsp Io By Dat Constructed Well Depth ft <br /> COMMENTS <br /> iz <br /> PE C Received Check#1 Amount Permit! <br /> Codes Info By Remitted Date Service Request Al Invoice# Wel11D# <br /> 43i-/ (p114 rl/ OD3 <br /> W 04!0809 <br /> 8104WELL/PUMP PERMIT <br />