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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 CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS In <br />k CITY/LP �-3? <br />CROSS STREET APN ,�3 PtARCEL SIZE S/ =J LAN ATI ON # I' <br />OWNER NAME --�`� � '` [ `-�'(t ��pH.NE �_� <br />OWNER ADDRESS 3 .5� /(V� �� �]O V UL.RAi—� � J'�., L�� CITYISTATE/ZJP ''A <br />CONTRACTOR .� K l —�c/v� Mi I U 0 f C rAifirllC <br />� ia�(i/��_(� PHON- (E� <br />CONTRACTOR ADORES/s Z NCT'O1 a�1D CSC -ice a� .FT�CII�TYISTATE(LP '-`^^-C./ t�� .�N/'jr _ <br />SUBCONTRACTOR VVI' \� tl �+�++`�- �C//t�/�O1��r PHONE`�(Y%/� �C15� �1�1 /7t <br />SUBCONTRACTOR ADDRESS �' ?/ asCO�. CICITY/STATE/LP w���1 CJS <br />LICENSE -57 C-61 _ _ D-09 Other NUMBERg&& -w EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ <br />INTENDED USE Domestm/Private mgatiorJAgncuitural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner W.I. ys em acre Uoriad Namit or ne Nl=er <br />TYPE OF WORK New Well Replacement Well Well AlleratiorVModifical ion WCtherr34M 4Q:te �kM-U r[w—I <br />Monitoring Wells) # of wells Soil Boring(s) nng5 Geotechnical K°r 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 Mud Rotary Air Rotary >a-er Cable Tool Push Punt Other <br />Proposed Well Depth_ . D R Excavation (I in d. ameler Open Bottom Gravel Pack/Gravel Size in diameter <br />Conduce+^• Casing in diameter / Ccnductor Casing Depth h <br />Well Casing Dlameier e _ in Th ckness/GaugeJASTM Sched !I L) Steel Ila lastic Stainless Steel Other <br />Grout Seal Depth 5 —f`0 it YNea' Cement (94,b bag/5.10 gal wafer) Sand Cement sack mix F7 gal water, <br />Benton to (20% solids) Other <br />Grout Placement Method%aumped Free Fall Other — _ _ Retardant / Accelerator (name) <br />PEDESTAL Installed By Dnller Pump Contractor Other <br />Concrete edestal Dimensions Width ft Length ft Thick in Christy Boxtove Pipe <br />MP Submersible Turbine Other HP Pump Se! 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 />MINIMUM 24 VANCE NOTICE REQUIRED FOR INSPECTIONS }- PLEASE CALL (209) 953-76 77f Q <br />SIGNED TITLE �Z�C.X�J-�.Xl �'�I DATE q10��/� 6 <br />D <br />a <br />A <br />iy <br />AA <br />7 ���G y <br />Fi�(,°R ?Ole <br />Cry��'�gRTM�� <br />NT <br />PA TMENT U E N L Y <br />Application Accepted By ' tf Data ff Areamployee ID#�-CX/" I <br />Grout Inspection By ate T /� SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Sal BOnng Inspection By <br />COMMENTS <br />Dale Constructed Well Depth R <br />PE <br />Codes <br />SC Received <br />Info By <br />Check#/ Amount <br />Cash Remitted Date <br />Permit) <br />Service Re uest # Invoice # Well ID# <br />EMO 43 O6 <br />4rl31ti : �6�� WELL !PUMP PERMIT <br />