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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 -(209)468.3420 <br /> NON-REFUNDABLE PERMIT LL(2091953-7,697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> n^L,p 1^� <br /> JOB ADDRESS ( I „ /�,` CITY/ZIP D <br /> Y / � <br /> CROSS STREET 1 APN (�1 '^ ) PARCEL SIZE IT, LAND USE APPLICATION# m <br /> A `p N <br /> OWNER NAME / ^^�! 1 ` / PHONE �� <br /> OWNER ADDRESS [C) �l' --_ CITY/STATE/ZIP t/ Ixo1,rs ,�] <br /> " " 1 <br /> n <br /> CONTRACTOR MA cLV `I.P"oE�,��9 <br /> CONTRACTOR ADDRESS ` I I C�.0 11J CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> rr <br /> LICENSE C-57 C-61 D-09 Other NUMSERa ll EXPIRATION DATE r, <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE DomestidPrivate _Irrigation/Agncultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> f d�lterent from Owner - -Water ys em ame ame or re u r <br /> TYPE OF WORK New Well Replacement Well Well AlterationlModification Other <br /> ( <br /> Monitoring WellOf pnn95 s) #of wells Soil BOnng(s) Geotechnical A Df I—ngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair_ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other Q ` <br /> Proposed Well Depth ft Excavation` in diameter Open Bottom Gravel Pack/Gravel Size in diameter ^ <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ___., Steel Plastic Stainless Steel Other <br /> Grout Seal Depth It Neat Cement(94 ID bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length It Thick in Christy Box Stove Pipe <br /> - l <br /> PUMP Submersible Turbine Other HP Pump Set_L&2 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 n <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M If���uM 24 HOUR ADVANCE NOTICE REQ I D FOR INSPECTIONS <br /> SIG `�W til TITLE l�r DATE <br /> el <br /> N <br /> i <br /> i <br /> # 7 - ME ISI ry TA <br /> T <br /> D PARTMENT US O LY <br /> 4C <br /> Application Accepted By 'T�` Area Employee ID# <br /> Grout Inspection Rv Date SPECIAL ell Permit <br /> Pump Inspection B ! - -� Date // � //- - WAIVER Received <br /> Soil Boring I�tion By Date r� Constructed Well Depth ft <br /> COMMENTS /fftC•L C.�S I�?P/'C�ZLY +fiL J �17Llte /4i*(4 Z r-iqT <br /> PESC Received Ctle-'o Amount Date PermlU Invoice 0 Well IDS <br /> Codes Info B Cash Remitted Service Request# <br /> AU,S e ' <br /> a�S9 a `� 3i"A / Koc � <br />