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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 T CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS V I CITY/LP. V14 T --I) I M <br /> �'i� -7 '/ 1�Q ) m <br /> CROSS STREET�� 1�(�// r e-e-R a'A1PIN�I - C�^7 r .+DEL SRE -G a (91 APPLICATION# <br /> OWNER NAME /r r�l n �" I)�-rI, rI Cyck / PHONk 1) O <br /> 900 <br /> OWNER ADDRESS I ran` ✓1• /. CITY/STATE21P (/ 64 <br /> y2� <br /> CONTRACTOR , G I I I� i/)G l_C� PHO E S ZZ <br /> r CONTRACTOR ADDRESS /C Sf. C"STATE/LP W, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE G57 C-61 D-09 Other NUMBER IL�1�a ExPRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE omeslicJPrivale IrrgatioNAgriculluml Industrial Water Oualily Monitoring Soil Sampling/Charactenzalion <br /> Public Water System <br /> r di'fero,t'rom Omer W.tor rem ameKnow or PooriC Numbvir <br /> TYPE OF WORK Naw WeN Replacement Well Well AlleralionlModificalion Other <br /> Monitoring Well(s) #of wets Soil Bw #01 borings ing(s) Geolechnical #o}borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ud Rot Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 0 tt Excavation_/ in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Dept fI <br /> Well Casing Diameter L in Thickness/Gauge/ASTM Schad,N-I Steel sl Stainless Steel Other <br /> Grout Seal Depth 4Oa it Neat Cemc7t(941Ibay/5�-10 gal wafer) Sand merit sack mix/7 gal water <br /> Bentomte(20%solids) Other /-(L/r—� 1 —P—/"Ylrl��/—d(�z�-a <br /> ,Grout Placement Method Pumped Free Fall Other R6tardanl/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length it Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS C PENSATION LAWS. �I <br /> UM HOU /�[1VANCE,Is(OTICE REQ TIRED F N C S- L CALL(209)953-769/71 <br /> SIGNED ` LE DATE 11L_1 <br /> u <br /> r <br /> m > <br /> f m3 <br /> N :Zm <br /> cm M ol v � <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 7—i f 26Z� Area Employee ID# <br /> Grout Inspection By /`1�— Date Z15 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By /prat Con3tructed Well th It <br /> COMMENTS "L rM r rITt1 T�L�• SP�7�!>L C Iti <br /> /ls8 t !1K y db-- 1eRwy/_L /Ob Aft. ft! X, 14,k 4e,/e '-yj <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well IDIt <br /> Codes Into B Cash Remitted Service Request A <br /> q /ga C'V 0 yy$ 2 2 5\5 <br /> 34 •� /� <br /> C,30112 a Oft V c.c V!a <br /> 4�3g/12 1 <br />