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WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AYE Y"FL-STOCKTON CA 95202-(204)"S-3420 <br /> NON-REPUNDABLE PERMIT <br /> /� /� Q CALL 209 953-7697 FOR INSPECTIONS - EXPIRES 1 YEAR FROM DATE ISSUED 3 <br /> JOBADDRVSS �� /V 6 7 '��S' �R RO CITYIZIP �1 <br /> CROSS STREETn} 9 OD <br /> ��/J•?Q'U4 APN - Z PARCELSIZE <br /> I—LAND USE APPLICATION fI <br /> OWNER NAME �.JM?27']�Ay� PHONE Z!2 <br /> OWNERADDRESS_ .//(.IL,J S- 7 A> <br /> E CITYISTATUZIP — <br /> ben <br /> CONTRACTORpp PHGNI; <br /> CONTRACTORADDRESS CtTVfSTATElZIP :12V—[/�]'`rJlyCA g..S7d3 <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS ~ �CyfrYISTATFJZIP <br /> LICENSE 13C-57 C-61 O D-09 [3 /Other NUMBER EXPIRATION DATE 7-47 <br /> GEOGRAPRICALINFORMATION: Coordinator X Y TOW-shlpB <br /> 5_ Range Section <br /> ]-TENDED USE DomeSlielNrivale 13 Irrigation/Agdcultural 17 Industrial 0 Water Quality Monitoring C7 Soil Sampiing/Characterialion <br /> Q Public Water System <br /> IfdiflermtkvmOwner. eta yrrem ams omen erase or na u r ,,- <br /> TYPE OF WORT( O New Well 0 Replacement Well 17 Well Aheratian/Modifiealion O Test Hole 0 Other v� <br /> 17 Monitoring Wcll(s} #of wells OSoil Borin s dof bnrinar #DfbDengc <br /> ❑Gealechniesl <br /> C]Well Destruction ❑Out-Of-Service Well O Out-Of--Service Well Renewal <br /> bLNeW Purnp O Pump Replacement O PuEag ReEir ❑Cross-Connection Repair <br /> WEr.L CONSTRUCTION '1 <br /> Drilling Method 11 Mud Rotary O Air Rotary 13 Auger O Cable Tool C]Push Point 0 Other 1{1`Rt►1_I+ <br /> Proposed Well Depth ft Excavation in diameter O Open Bottom O Gravel Pack!Gravel Size in diameter <br /> ❑Conductor Casing in diameter I Conductor Casing Depth ft + <br /> Well Casing Diameter_in ThickneWGauWASTM Sched O Steel O Plastic ❑Stainless Steel ❑Other KvA\+ <br /> Grout Sed Depth ft 0 Ncat Cement(941h bag/J-10 gal wafer) O Sand Cement sock mar J 7 gal water <br /> ❑Bentonite(20/.solids) O Manufacturer Spec e/solids_% Name O Specs on File O Specs Submitted <br /> Grout Placement Method O Pumped O Free Fall t]Other 0 Retardant!Accelerator(name) <br /> PEDESTAL Installed By 17 Driller QPump Contractor Other <br /> Concrete Pedestal Dimensions: Width ft Length ft Thick jrr in [,Christy Box 13 Stove,Pipe <br /> PUMP b6ilimersible O Turbine Cl Other Hp Pamp Set as f1 Standing Water Level R <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITHSAN <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 <br /> WORKERS COMPENSATION LAWS. AND THAT I AM IN COMPLIANCE WITH ALL <br /> IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS l <br /> STGNEIDTITLE DATE <br /> -------------- <br /> -- --------------f--$--------- <br /> ---------------- <br /> ------------- <br /> D P RTMENT USE ONLY <br /> Application Accepted By Date �-Qc7 Arm�. Employee ID# rQaV <br /> Grout Inspection Dale Q SPECIAL Well`Permit <br /> r � <br /> Pump Inspection By Dale "� ❑ WAIVER Received <br /> Destruction Inspection By Dale Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received Chec Amount PermlU - <br /> Codes Info H Cash Remitted Date Service Request# - Invoice# Well ID# <br /> EHD 43-02-W <br /> I #IROI _ WELLPUMP PERMIT <br /> f <br />