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WELL/PUMP PERMIT <br /> SANJOAQCIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"'FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERb�JHT C k L(209)953-7697 Eo INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSTI CITYIZIP <br /> L- � (/ a <br /> CROSS STREET � APIt-�{V' � ARCE.I.SI7.F-�.] LAND USE APPLICATION A <br /> OWNER NAME � ,..{� <br /> r1l - PHONE _ <br /> OwNERADDRESS V` CI"IY/STATF/ZIP [ (� <br /> CONTRACTOR PHONE /jj'I17yv" �'(yjQlZp�'y I- <br /> CONTRACTOR ADDRESS _ CITYISTATE/ZIP '{- <br /> SLBCONTRACTOR ,.. -_ PHONE <br /> SUBCONTRACTOR ADDRESS 'CIITTYISTATE/ZIP _ <br /> LICENSE -57 C]C-61 ❑D-09 E3 Other NLMBER d�/ 0!j6q E%PIRATION DATE O _ <br /> GEOGRAPHICAL INFORMAIION: Coordinates X Y l'ownship Rang! Section <br /> INII:NDED USF. O Domestic/Private XrrigationlAgricultural ❑Industrial ❑Water Quality Monitoring O Soil;Samp�iinVgiChamctcriz-ation❑Public Water Syystem <br /> If drtrerearf 0,..- stet ys". sme <br /> TYPE OF WORK ❑Vcw Well ❑Replacement Weil O Well Alreration.'Modification ❑Other <br /> ❑.MonitoringWell(s) pofwclls []Soil Barin s uotb'"ar aorsodos, j <br /> gO ❑Gmtechnical fl <br /> ❑Oul-Of-Semcc Well ❑Out-Of•Semice Well Renewal ❑Cross-Connection Repair <br /> New Pum O Pump Replacement O Purnp Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary O Air Rotary Q Auger ❑Cable"fool 0 Push Point ❑Other <br /> Proposed Well Depth ft E cavauon in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_,in ThicknessiGauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel O Other <br /> Grout Seal Depth __ft ❑\eat Cement(94 1b bag 15-10 gal water) ❑Sand Cement sack mit/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name O Specs on File ❑Specs Submitted <br /> Groin Placement Method O Pumped ❑Free Fell ❑Other ❑Retardant I Accelerator(name) _ <br /> PEDESTAL Installed By ❑Driller Cl Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in 17 Christy Box ❑Stove Pipe <br /> P ❑Submersible Turbine ❑Other IlP Pump Set it Standing <br /> UMP Water Level ft <br /> 1 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 MV 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 /> 1 M171 I Nt 24 HOUR ADVANCE NOTICE RE1 U RED FOR INSPECTIONS <br /> TITLE T DATE <br /> I <br /> I <br /> I <br /> I <br /> Y i <br /> V <br /> u <br /> 5NAJ fE <br /> N E <br /> i <br /> i <br /> /DF:P H S1ENi SE V LY /J <br /> Application Accepted 83�j ` Date,/7�%� Area _-- Employee IDA wl <br /> Grout Inspa;tiun By _ _ Dale _ ❑ SPECIAL Well Penult <br /> Pump Inspection Hy _ Date 224-13!2 11 WAIVER RCCC1VCd <br /> Constructed Well Depth ft <br /> COMMENTS L.�f-fail,yj7LG�.t;�l��'.��Ly.,�v�97�=1C��/L <br /> 1�-i/� l�-�-�r-�zzl.s�ar�En}z4l.l <br /> PE SC Received sr / Amount Permit/ <br /> Codes Info By ash Remitted Date crvcc Invoice# Well IIF# <br /> ��log eA 2 wo 2ro 8?J <br /> END 43.01-006 '-ELL PUMP PERMIT <br /> 1R7!:OOS <br />