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WELL/PUMP PERMIT <br /> SAN JOAQUIN CCUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 -(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4;,p.qjrA N <br /> JOBADDRESS ���✓y' `� • �Q• '�-� • CITYZP YT770194'�LL_Q�y 2 D <br /> CROSS STREET / APN SOT wV V� PARCEL SIZE/14'*t4_LANO USE APPLICATION f <br /> jIy",/�,�A 1• g�vwto \) 07 S<Ly-/moo � <br /> OWNER NAME �` Ar i`�; ►I ia�n���(�Lo 1 iQ Tr Ad 4*1/ PHON / I �J <br /> OWNER ADDRESS �I�-Wl,ne.('.YetAL F+� - CITYISTATE/LP �J 2170 <br /> CONTRACTOR � ( PHONE(2 QTS — '''31 <br /> CONTRACTOR ADDRESS CITY/STATEZP�]'MYH I, A 0537 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS -- CITY/STATE/LP <br /> LICENSE C-57 C-61 D-09 Other NUMBER ZZs l EAPIRATION DATE <br /> GEOGRAPHICAL INFO RMA Ordinates X _Y Township_ Range Section_ <br /> r' <br /> i INTENDED USE omestic'Privals tura) Industrial U Water Quality Monitoring Ii Soil Sampling/Characterization <br /> em <br /> it dirrerenf hom Ownar. a.ar y.em ame o a or one N.rr r <br /> TYPE OF WORK XNew WeII Replacement Well C3 Well AltefationJModificatlon L Other <br /> Monitoring Well(s) R of wells J Soil Bodng(s) a of borings Geotechnical <br /> Cut-Of-Service Well 0 Out-Of-Service Well Renewal J Cross-Connection Repair <br /> New Pum U Pump Replacement Cl Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mud Rotary n Air Rotary f.',Auger -)Cable Tool 7 Push Point D Other <br /> Proposed Well Depth 4'*b ft /Excavation _;44 in diameter 7 Open BoLtto/m� II(Gravel Pack/Gravel Size td in diameter <br /> Conduct Casing 0 in diameter I Conductor Casing Depth /4 _tt <br /> Well Casing Diameter c n auge/ASTM Schad C Steel L7TPlastic C Stainless Steel Other <br /> Gro eplh et Cement(94/b bag/5-10 gal wafer) Sand Cement �� sack mix/7 gal water <br /> „Bento I (20 A so ids) i1 Other <br /> Grout Placement Method Pumped <Free Fall .,Other U Retardant/Accelerator(name) <br /> PED Installed By Driller Pump Contractor Other <br /> L '?Concrete Pedestal Dimensions:Width R Length R Thick in ^ Christy Box Stove Pipe <br /> I <br /> (PUMP Submersibles Turbine ❑Other HP Pump Set ft Standing Water Level 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 /> MINI M 24 HOUR ADVANCE NOTICE REQU ED FOR INSPECTIONS <br /> / <br /> SIGNED TITLE DATE LIS <br /> 7 <br /> � D <br /> ~ 14 <br /> ouNTY <br /> AL <br /> TMENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By !V1' Dale Z L Area C Employee IDR <br /> f �� � . <br /> Grout Inspection By Dale ,/ �J///TG 0 SP CIAL Well Permit <br /> Pump Inspection By Date n WAIVER Received <br /> Suit Boring Inspection By Date Coenstructed WI Depth iL <br /> COMMENTS "J[( - 11�L - J s 22Y,(11a <br /> .�.. 9. r{'��. G' C�. <br /> PE Sc Received ec1aW Amount Date PermiU Invoice R Well IDR <br /> Codes Info B Remitted Service Request R <br /> 436`1 1�c <br /> ENC 43-08 <br /> nn<r�c WELL(PUMP PERMIT <br />