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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868E-Ai HAELTON AVENUE-STOCNTON CA 95205-(209)46"20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> _N <br /> JOB ADDRESS 300'ra AJA\N 't7R Crtv/Z0P STOCk ION / gS906 �yy <br /> CROSS STREETT-ORS26 STA L APN IHS02AR <br /> 01i PCELSRE-IS 5- LAMDUSEAPPUCATION# bo <br /> OWNER NAME ;Toclrc7\O"/ - PHONE <br /> Ll I <br /> OWNERADDRESS 'J.N.r//t� •aY• �V�STIY •� N OS IF'` CITY/STATEIZIP.<TOCkToN, cA, qsw i <br /> CONTRACTOR <TA/AvTEC PHONE 916 ,.=43-91100 <br /> CONTRACTORADDRESB 7i Ts 7-T is ITIER 10N RL cR21 <br /> Y/sTATEP'ROCkLLjy, 6A <br /> SUBCONTRACTOR GASCAD& nRSLLINGl PHONE 4116 - -x•10- 46H <br /> 1 <br /> SUBCONTRACTORAOORESS ap S 13rcL CIWlSTATE/ZIP R-rr-HAf%0 �DjGA,9H <br /> pbo'f <br /> LICENSE /C-57 O$1 L.D-09 I Other NUMBERaa2i 110 EXPIRATION DATE ojLjoi <br /> GEOGRAPHICAL INFORMATION: Coordinates% Y 1. Township_ Range_ Section_ <br /> INTENDED USE Domestic/Private ImgationlAgricultual Industrial I_'.Water Quality Moni ring Soil Sampling/Characterization <br /> uemennmm,,. Wear Syri Narre Garad Namew neum M <br /> TYPEOFWORK New Well . Replacement Well Well AlteationlMOdigcatlen Other <br /> Monitoring Wells) #of wells Soil Borings) #arlwelea I/GOotachnical I;L pmhoxree <br /> Out-Of-service Well Out-Of-Service Well Renewal -Cass-Connection Repair <br /> New Pump Pump Re lacemert Pump Repair -Raise Well Casing <br /> WELLCONSTRUCTION ' ` , I <br /> Drilling Method Mud RRotary�,._ Air Rotary -Auger Cable Tod Push Point c Other {-IOIION .S+C� iProposed Well Depth YOI Excavation in diameter Qpen Bottom Gravel Pack/G2vel Size in diameter <br /> Conductor Casing_in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTMSchetl Steel Plastic Stainless Steel i-.Other <br /> Grout Seal Depth It ✓Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mixfT gal Water <br /> Bentonite(20%solids) ..Other - <br /> GroutPlacementMethod - Pumped Free Fall dOthar7RI M/dL c Relerdant/Accelerator(name) <br /> PEDESTAL Installed By _ Driller 7 Pump Contractor I Other <br /> Concrete Pedestal Dimenslons:Wdth_ft Length ftThick in I Christy Boz Stove Pipe <br /> PUMP Submersible. Turbine iOther HP Pump Set ft Standing Water Level ft <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 /> MIN=R OVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953. 697 <br /> SIGNED TOLE PYO 1' r T7� DATE 7 1 1 <br /> ti O� <br /> U)` <br /> ,y 2 <br /> os? <br /> EPARTMENT USE ONLY -•r- /J <br /> Application Accepted By Date Area I Employee lD#• I rl?(V70CLLCi� <br /> Grew Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Baring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Data Perm lV Invoice# WeII[DO <br /> Codes Info B Cash Remitted Service Re uest# <br /> �z Isv dyes <br /> EHD4306 WELL RUMP PERMR <br /> 400112 <br />