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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE.PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS `da(Do S _VA wtvi C{ v <br /> �J � CITY/ZIP 5[c.+L.k�-'Q h Z 2-1 J ~ <br /> Q� /' D <br /> CROSS STREET " lAPN.�� D✓ v PARCEL SIZE LAND USE APPLICA IIION# <br /> OWNERNAME C_ca/l �O✓hl(�i IYyL[`I Yee P—, PHONE_ ��, I�r'-J(r'f/ ^47-1'�. . <br /> OWNER ADDRESS ZO&0 5 EI-l�ah la�1 CITY/STATE/ZIP ` 0C.(CtO YY J CR G S- <br /> CONTRACTOR K L E 1 N P L-L[)L 12 O n e 1PHONE <br /> CONTRACTOR ADDRE&S �� r�'�'-tP S CITY/STATF./ZIP <br /> SUBCONTRACTOR rOVV'Yy Er LJt 1"1 h,.� _ PHONE $OO—2-0 — 1 <br /> SUBCONTRACTOR ADDRESS �-0- t%A CITY/STATE/ZIP LI A&"\ C ft (� <br /> LICENSE C-57 D C-61 D D-09 D Other NUMBER SQ <br /> ordiEXPIRATION DATE &�v]o /Q <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Ranee__ Section_ 1�\_ <br /> INTENDED USF. D Domestic/Private D Irrigation/Agricultural ❑Industrial D Water Quality Monitoring D Soil Sampling/Characterization O <br /> D Public Water System_ <br /> Ifdlffc n,Eon Owner. aver System am ___e ODnac erne or oar Lm r - -"- <br /> TYPE OF WORK D New Well D Replacement Well D Well Alteration/Modification D Test Hole O Other <br /> aof Wangs r n <br /> D Monitoring Well(s) #of wells ❑Soil Boringa.fborings <br /> Boring(s) WGcotechnical 3 V <br /> D Well Destruction D Out-Of-Service Well D Out-Of--Service Well Renewal <br /> O New Pump ❑Pump Replacement D Pump Repair D Cross-Connection Repair <br /> WELL CONSTRICTION '' <br /> Drilling'Method D Mud Rotary D Air Rotary KAugeT D Cable Tool D Push Point D Other <br /> Proposed Well Depth j_S-=2�0 R Excavation in diameter D Open Bottom D Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing_ __ in diameter / Conductor Casing Depth R <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ___ D Steel D Plastic D Stainless Steel D Other <br /> Grout Seal Depth R D Neat Cement(941h hug/5-10 gal water) D Sand Ccmcnt_ crack mir!7 gal water <br /> D Bentonite(20%solids) D Manufacturer Spec%solids % Name Me-Pho I tC Gt^W+d D Specs on File ❑Specs Submitted <br /> Grout Placement Method D Pumped D FTee Fall D Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller D Pump Contractor D Other _ <br /> D Concrete Pedestal Dimensions: Width_ R Length_fl Thick in D Christy Bos D Stove Pipe ^ <br /> PUMP ❑Submersible D Turbine D Other HP Pump Set__fl Standing Water Level R �) <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 /> iINIMUM 24 HOUR ADVANCE NOTICE <br /> 2REQUIRED FOR INSPFC 1' ON <br /> SIGNED ^_•,(/ TITLE �r y/e 1}•=`•y r� ,ATE ` • `" �r <br /> O rJ <br /> d; ' N _ WT <br /> r_ 1 <br /> c t <br /> 8) r to 0our <br /> r _ o <br /> A <br /> DEPARTNIENT USE E ONLY <br /> Application Accepted By 4-4z'a;zDate S/G� - Arca _ Employee 11345 <br /> Grout Inspection By Date 1 ❑ SPECIAL Well Permit /fJ <br /> Pump Inspection By Date, ❑ WAIVER Received <br /> gtrg Inspection By Date S _ Constructed Well Depth It <br /> COMMENTS -- — - ---- —- <br /> PESC Received Cher Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By .esh Remitted Service Reguest# <br /> �-��, �'p / �•Ou 5200 aea <br /> i <br /> •, n <br /> —1 _ i w SY, .11 <br />