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«'�►, _. ;,�' � r:I�'t„�l S Cct � l I -'1 � -I c; �1 sw. I y ��i y � - N a� WELUPUMP PERMIT O.iAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT (CALL 209)9553-7697 FOR INSPECTIONS �EXPIRES 1 YEAR FROM DATE ISSUED JOB/ADD f .� ^�!_ —�p� CITY2ZIP� CRHSS STREET / 1vs-Tiy /`� APN 010 � D/!J '-7T PARCEL SIZE -+/ 5 LAND USE APPLI-C7ATIONN�#j OWNER NAME / � y, tp` �',''�f� �/P�HJOONE OWNER ADDRESS Ol/�/ / , 5HAQ/ W �Y�2C�2-yF�- 1_/V w CITY/STATE/ZIP � CONTRACTOR PHONE 7� PHONE �AZD LU�i�CLJa' /�� CITY/STATE/ZIP G CONTRACTOR ADDRESS SUBCONTRACTOR //"/L+L_�S� /f+� PHONE SUBCONTRACTOR ADDRESS LICENSE V.) C-57 1 f) D-09 11 Other NUMBER CITY/STATE/ZIP EXPIRATION DA GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private CI Irrigation/Agricultural f] Industrial f_i Water Quality Monitoring ❑ Soil Sampling/Characterization I 1 Public Water System It different from Owner: Water System Name ontact Name or Phone Number TYPE OF WORK lew Well Ll Replacement Well ❑ Well Alteration/Modification ❑ Other Z xLa _ # of borings IJJ ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) ❑ Geotechnical O 2 W El Out -Of -Service Well Ci Out -Of -Service Well Renewal ❑ Cross -Connection Repair :LI c� 0,* borings /New Pump uPump Replacement U Pump Repair n Raise Well Casinq Q ttt� � O PSS WELL CONSTRUCTION Vn cc Z OZ J Drilling Method �Vlud Rotary ❑ Air Rotary C Auger ❑ Cable Tool [I Push Point ❑ Other �L W Proposed Well Depth : �-) r, Excavation _ `5r in diameter ❑ Open Bottom ravel Pack/Gravel Size i iantter ❑ Conductnr Casing in diameter / Conductor Casing Depth / ft Well Casing Diameter"_rCi I nipkness/Gauge/ASTM Sched Cj— U SteeI AVPlastic ❑ Stainless Steel ❑ Other Grout Seal D th __,�Om _ ft \ l Neat Cement (94 lb bag/5-10 gal water) Sand Cement !l�'� sack mix/7 gal water (_I nite 2 %_ sluts) f 1 Other Grout Placement Method JWPumped _1 Free Fall r Other U Retardant / Accelerator (name) 1 PEDESTAL Installed By ❑ Driller APump Contractor ❑ Other 17 Concrete Pedestal i. D' ensions: Width ft Length ft Thick in D Christy Box ❑ Stove Pipe PUMP Submersiblef I Turbine f Other HP 2 Pump Set Z; � ft Standing Water Level s ft I HEREBY CEfITIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS, MI ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95)3-76P7 SIGNED TITLE �f/l� DATE _ . . . . . . . . . . Check#/ Cash \. Date Permit/ Service Request # Invoice # Well ID# . . V 3 �� ,o �� Clz V3'�► . . . .. . . . . . . .Wz 1 �o Ci20��(332yj . . . . . .� . 1 f 3o OU�I¢33I � z w.... .... .°. . w gg.yy_. aSQ}�itn D r . . . . . . . . . . . . . . . . . s% .9 z i� . . . . . . . . . . . . ..rnvr�uaa� , m D Mm m ur ETMENT USE PNY +� Application Accepted B Date Area Employee ID# U Grout Insnoctinn Pty Date L SEC AL WCII rCCilllt Pump Inspection By Date Q WAIVER Received Soil Boring Inspection By COMMENTS Ma ConjUucted Well Depth ft PE Codes SC Info Received By Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Well ID# V 3 �� ,o �� Clz V3'�► w�oo3�5�i2 1 �o Ci20��(332yj roo16 113 f 3o OU�I¢33I r i%� �/ / 1V v 11 I/LO/I� WELL /PUMP PERMIT