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2'•� <br /> r WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAW STREET-STOCKTON CA 95202 -(209)46113420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> / r � <br /> Joe ADDRESS Il a{� 9 22 rCITYfzjp �!N� �q D <br /> CROSS STREET —M;1470 APN J 0�'liiPARCEL SIZE 12.6 LAND USE APPLI ATtON# ,TOp <br /> OWNER NAME PHONE S�^i <br /> OWNER ADDRESS <br /> CITYISTATE/ZIP <br /> CONTRACTOR _ Q yQ. I's V Yl)ll I we PHONE GO <br /> CONTRACTOR ADDRESS 74I D,S r�rl CRY/STATE/ZIP Z�10 ,e-.j -1/� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATI11i <br /> LICENSE C-57 D C-61 n D-09 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Rani Section_ M/l►'�` <br /> INTENDED USE )DomestidPrivate ❑Irrigation/Agricultural o Industrial D Water Quality Monitoring O Soil Sampling/Characterization lr, <br /> Public Water System "{ <br /> f different from Own r ams ems or one u r <br /> TYPE OF WORK New Well G Replacement Well D Well Alteration/Modification Li Other <br /> D Monitoring Wells) #of wells D Soil Boring(S) •of borings p Geotechnical 9 of bodngs <br /> Out-OfService Well D Out-OfSeMce Well Renewal D Cross-Connection Repair <br /> New Plump D Pump Replacement C Pump Repair U Raise Well Casio <br /> WELL CONBTRUCTTON <br /> Drilling Method XM Mud Rotary D Air Rotary ❑Auger L Cable Tool c Push Point ❑ Other <br /> Proposed Well Depth 2ZrD ff Excavation e'Z- in diameter L Open Bottom C Gravel PadJGravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter &p In Thickness/Gauge/ASTM Schell vL0 O U Steel lastic C Stainless Steel L-I Other <br /> Grout Seal Depth &he it C Neat Cement(94 lb bag15-10 gal water) nd Cement sack mix(7 pal water <br /> 4KBentonite(20%solids) IJ Other <br /> Grout Placement Method Pumped Free Fall Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed BY u griller Pump Contractor -i Other I <br /> D Concrete Pedestal Dimensions:Width It Length ft Thick in ❑Christy Box D Stove Pipe <br /> PUMP - SubmersibleC Turbine D Other HP Pump Set ft Standing Water Level ft <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. I <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FORINSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED f C /"`�2%_ "� TITLE l�K(Il Pw DATE <br /> > C4- - 1 <br /> I - <br /> r � L41J <br /> rL <br /> N L <br /> R T M E N T"U S t—jD N L Y- <br /> ` <br /> Application Accepted ` Date Area Employee ID#_ �] c <br /> Grout Inspection By Date La < SPECIAL Well Permit <br /> Pump Inspection By Date 11 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received hec Amount PermlU <br /> Codes Info B Oete Involve# Well IDtI Remitted Service R nest# , <br /> I, i <br /> ENDWELL/PUMP PERMIT <br /> fi2&C9 <br />