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WELL/PUMP PERMIT /� [F)V <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209}46 2 �1 1\NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YFAR FROM DATE IS l��t\��Ji�1 J1 <br /> ` <br /> QLY <br /> Jos ADORE39 S / S. ra /ro„d CeryljUp ,,,�f s <br /> 6'1 st .+N� o <br /> k// /CY✓L' All <br /> PARCEL SIZE 1LANO IISE APPLICATION# <br /> CROSS STREET ,am <br /> OWNER NAME / - PHONE .g na Ivqso <br /> OWNERAWRESS 345"3Z S• CITYISTATE2P r 01 <br /> CONTRACTOR feinirE -r 3 <br /> -_... _ �J_ 1_ _ PHONE, 6!7"9) <br /> CONTRACTOR ADDRESS "001 A/Y/j`At1 an /SaNC CrTYISTATEMP Xr-eA7tt*1 CLZ <br /> L� gvS-a�7�D <br /> SUBCONTRACTOR Op ee ifJo,a SQM{CJ/i�1y -T4e <br /> k <br /> SUBCONTRACTOR ADDRESS 2365 L.l+ y✓sih•n .d�)"r� CIITYYISTAtelz-r}P <br /> NSS7xJt7o, Ck SaoS <br /> LICEE Y,C-57 I]C-61 n D-O9 ❑Other NUMBER O.S .Eo / EXPIRATION DATE 1�3��.ZalD <br /> GEOGRAPHICAL INFORMATION: CoordinaWs X 6/6gy S Y -JR)- 3 S6l9'S Township_ Range Section_ <br /> INTENDED use ❑DomestldPrivate D InigationlAgnouftural D Indusrrlal ❑Water Quality Monitoring Soil Sampling/Charaderization <br /> ❑Pubic Water System <br /> NditrelHaam Owner: er bYSIeM a ne nm <br /> i <br /> TYPE OF WORD ❑New Well n Replacement Well D Well AllerationlModitication D Other <br /> ❑MOnitodngWetl(s) III of"IlsN,SoilBDring(s) s016of- ❑Geotechnical 0ofborings S\ <br /> C Out-Of-Service Well ❑Out-OfServloe Well Renewal ❑Cross-Connection Repair Or <br /> D New Pump C Pump Replacement ❑Pump Repair D Raise Well Casing [1�7 - <br /> WELL CONSTRl1C710N <br /> Ortfling Method ❑Mud Rotary ❑Air Rotary ❑Auger D Cable Triol n Push Point 0 Other <br /> Proposed Well Depth V O R Excavation in diameter ❑Open Bottom ❑Gravel Padd$Tavel Size in diameter l� <br /> G Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Dlameter_in ThicknesslGaugelASTM Schell D Steel D Plastic D Stainless Steel ❑Other <br /> Grout Seal Depth ft D Neat Cement(94 1b hagl&10 gal water) D Sand Cement sack m(xl7 gal water <br /> ` <br /> D Bentonite(20%solids) S Other //0/, P/✓9NATPF- el Coin le i O F�LXe- <br /> Grout Placement Method ❑Pumped 4 Free Fall D Other ❑Retardant/Accelerator(name) - - <br /> PE�DESTAL Installed By D Driller ❑Pump Contractor ❑ Other <br /> n Concrete Pedestal Dimenslons:width ft Length ft Thick in D Christy Box 0 Stove Pipe <br /> 1 PUMP D Submersible[]Turbine D Other HP Pump Set It Standing Water Le%iel tt <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 /> IN UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS �/ q <br /> &GNE TrTLE/ioie1--r Ein[C� DATE <br /> k <br /> - <br /> .� o O Al <br /> --DEPARTMENT USE ONLY <br /> Y�_ s' <br /> -�--------- - -- <br /> App9raien Accepted By Date '2 'Y ^Area Employee IDN 'S <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By WAIVER Received <br /> Sol Bering Ins im By Date G Cons cted Welt Dept ft <br /> COMMENTS ! - _ <br /> PE SC Rece Amount PermW <br /> Codes Into B Cash Remitted Date Service Re st# Involve# Well ID# <br /> 16013w2-1 sg3ev.V1n <br /> 1 <br /> EHP 43-M WELL IPVMP PERMIT <br /> Bud= <br />