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t( l(; i? <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT L CALL 209 9533--7/6p97 FOR INSPECTIONS c EXPIRES I YEAR FROM DATE ISSUED <br /> Joe AccRESS V ./ u Ave, 'j _ Cm/LP J U I I r b D <br /> CROSa STREET APN �^ PARCEL SIZE L LAND,USE APPLICATION# <br /> OWNER NAME V �I �) /t� F I i P. <br /> rIr/ <br /> OWNER ADDRESS ! r- A � `" vv <br /> [AAfJ I / O <br /> CONTRACTOR /I �L� I�' / 1. C 1 P--d /l-k b �. <br /> CONTRACTOR ADDRESS l/(/�� �✓L - �� $TAT "—/ /�_J <br /> SUBCONTRACTOR / / 1 /�/' PHON.7-' r • ' V` <br /> SUBCONTRACTOR ADDRESS ' 1 // CRYISTATFJZIP <br /> LICENSE C-57 C-61 D-09 Other <br /> NuMBER_ EminAin N DATE <br /> GEOGRAPHICAL INFO ATION: Coordinate$X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private mgatiorvAgricultural Industrial Water Quality Monitoring Soil Sampling/Charactenzation <br /> Public Water System <br /> If dwerent from Ownx* Water SyStern Nanie UOrlIsd Nams or Phone NUfrJW <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> MonitoringWell(s) #of wells SoilBoring(s) #orbonngs Geotechnical oofbonrya C� <br /> Out-Of-Service WeilOut-0f-Service W II Renewal Cross-Connection Repair Y <br /> Nvx Pur Pur Ra larament m„m Ra air Roue Well Casin (� <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tod Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Sae in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainloss Steal Other <br /> Grout Seal Depth ft Neat Cement 1`94 It,bar15-10 ga!water) Sand Cern;'1 sack mix/7 gal water <br /> Bentonite(20%solids) Other__ _ <br /> Grout Placement Method Pumped Free Fell Other _ Retardant/Accelerator(name)Y <br /> PEDESTAL Installed By Driller . Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width__R Length_ ft Thick in Christy Box Stove Pipe <br /> Pump Submersible Turbine Other 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. 1 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 /> MINIM M 24 HOUR ADVANCE IOTICE REQUIRED FOkZ INSPECTIONS-PLEASE CALL(209195;-7697 'A <br /> SIGNED .O' - T. " V L LIP <br /> �II � DATE ` V� <br /> POO 1 1 2016 <br /> I <br /> E(�[VIRQ�!�gENTAL HEALTH <br /> PERMIT/SERMES <br /> OV2� <br /> DEP RTMENT PSEIONLY <br /> Application Accepted Bk Date(� Area Employee <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date _, WAIVER Received <br /> Soil Borng Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC 7 ReceiveT,,�pyT.n.-T— PM; '---�--- <br /> �y Date invoice 4 Weil ID# <br /> Codes Info B --t;erirl Remi ServiuRecuraat# <br /> &70,� I�( Zz leo St2no7►�282 P Of <br /> l � <br /> I <br /> WELL/PUMP PERMIT <br /> �/!0 2 <br />