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WELL/PUMP PERMIT <br /> SAN JOAQVIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-PL-STOCKTON CA 95202 •(204)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 1+OR INSPECTIONS EXPIRES 1 YEAR FROM D E <br /> LD <br /> JOB ADDRESS 31l. LI A h 2"li rA t' crrvrzip `r c cc)`F _ \\ I Y <br /> CROSS SrREer,.wl. clopy <br /> e)n SLn A n Y d APN ZC7S`EJ '? PARCEL SIZEAl LAND USE APPLICATIONOn <br /> ' OwNERNAME `t�LC�' \e(���` q% r� PHONE <br /> OWNERADDRESS � ttLiG ` 0.C1� `cce-r- N11�- CnY/STATLMP,W Ck,3Ck 9q560 <br /> w t4C <br /> CONTRACTOR �{ c4a, �ta 11>t 4L @��.'DC3►4 asz�tt----arc , PHONt$'j;:5=26IU <br /> C316{ <br /> CONrRACrOR ADDRESSO OX S Cal CtTYlSTArElZi n cr. Ca. 9S3 <br /> SUBCONTRACTOR PHONE <br /> } <br /> { SUBCONTRACTOR ADDRESS CMYISTATFJZIP l(� <br /> i LICENSE 0 C-57 O C-61 ❑D-09 Othe NUMBER�?-399�� EXPIRATION DATE V' <br /> CEOGRAPHtCALINPORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE meatie/Private ❑Irrigation)Agricultural ❑Industrial 0 Water Quality Monitoring 0 Soil SamplinglChawcterirafion <br /> 1 ❑Public Water Ssostem <br /> [i different from 0r ' W&W yuem oma mc[ ane eNaffMer <br /> t TYPE Or WORK 0 New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) b orwells O Soil Boring(s) N of to i"as 0 Geotechnical a OrLonngF <br /> 0O.'-Of- rvice Well [3Out-OFService Well Renewal 13Cmas-Connection Repair <br /> O New Pum Pum R laeemeot O Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary ❑Auger 0 Cable Tool 0 Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑Gravel Pack/Grovel Size in diameter <br /> 0 Conductor Casing in diameter t Conductor Casing Depth ft <br /> Wet]Casing Diameter_in ThickncW0auge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth it 0 Neat Cement(941h bag/5-1O gal water) 0 Sand Cement sack mixt 7 gal water <br /> 0 Bentonite(20%solids) 0 Manufacturer Spec%solids % Name 0 Specs on File ❑Spces Submitted <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller 0 Pump Contractor ❑ Other <br /> 0 Concrete Pedestal Dimemlorts:Width ft Length R Thick in 0 Christy Box 0 Stove Pipe <br /> Submersible 0 Turbine ❑Othcr HP Pump Set C,Q r ft Standing Water Leve].�_fl <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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE HOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE RFQUIRED FOR INSPECTIONS /� <br /> SICNPp��, C1�n�(_'� TITLE DATE z(11106 <br /> i <br /> V 11 <br /> r <br /> is <br /> i4 g 1� <br /> el <br /> 9 F <br /> ' DV ARTMENT U E ONLY <br /> �9Application Accepted B Dau Area Employee IDN - <br /> Grout Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspection By Date S M WAIVER Received <br /> 1 Constructed We pth ft <br /> COMMENTS <br /> PE Sc Received Choc Amount Permit/ <br /> Codes [pro H Cash Remitted ate Service R nest# Invoice# well ID# <br /> f D <br /> END 43-02-W WELL PUMP PERMIT <br /> tmnaos <br />