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WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 000 EAST MAIN STREET-STOCKTON CA 95202 -(2119)488.5420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7 97 FOR INSPECTIONS 1 EXPIRES 1 YEAR FROM DATE ISSUED <br /> ClTYZP <br /> Joe ADDRESS v O�O�� <br /> 0 <br /> 'Yl? rn) _ ApN PARCEL SIZE� LAND USE AppLICAnoN# to <br /> CROSS STREET �-- <br /> OWNER NAME (.�'1!f 1L. ��n l PHONE 'faG1 /—I h'SL7 <br /> n i IE CITY/STATE/ZIP <br /> OWNER ADDRESS , `�- , <br /> _ CONTRACTOR P->"W1'f1b g61 ?90 PHONE ... <br /> CONTRACTOR ADDRESS CITY/STATEIZIP -- <br /> PHONE <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE G C-57 ❑C-67 D-09 Li Other NUMBER ExPIRATKm DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTEt40ED USE 0 DomestidPrivate �] lmgationlAghCuftural 0 Industrial ❑Water Quality Monitoring _Soil Sampling/Characterization <br /> D Public Water System a ame or um r <br /> If diHerenl from Owner ys em me <br /> Type OF WORK C New Weil 7 Replacement Well 0 Well Alteration/Modification 0 Other a Iwn�s <br /> - <br /> Monitoring Wells) #of wells D Soil Borings) <br /> Mabwr'p Geotechnical <br /> 0 Out-Of-Service Well G Out-0W ( <br /> Out-Of-Service ell Renewal Gl —s-Connectlon Repair (�1 <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair O Raise Well Casing" <br /> WELL CONSTRUCTION D\ <br /> Drilling Method ❑Mud Rotary O Air Rotary --iAuger0 Cable Tool 0 Push Point 0 Other � <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom :1 Gravel Pack/Gravel Sae in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic n Stainless Steel Other <br /> Grout Seal Depth it 0 Neat Cement(94 Ib beg/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> Li Bentonite(20%solids) ❑Other <br /> Grout Placement Method 0 Pumped C Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor a Other — <br /> LI Concrete Pedestal Dimensions:Width ft Length ft Thick In 0 Christy Box --Stove Pipe <br /> MP C Submersible?Turbine 0 Other HP Pump Set it Standing Water Level <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)957697 <br /> SIGNED �ti` --� TITLE , l/f)/�"e, DATE <br /> 77-7777 <br /> s <br /> E V O N <br /> A N <br /> Li <br /> DEPARTMENT`LJSONLY ' <br /> Application Accepted By. Date Area Employee ID# <br /> Grout Inspection By Date 0 SPECIAL Well Perrinit <br /> Pump InspectionDate D WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS ` <br /> PE SC Racal ed Amount Date Pe IV Invoice# Well IDN <br /> Codas IMo @ s Remitted Seryice Request# <br /> IfA � 5D Sbd d r_S <br /> 612609 <br />