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T.z WELL/-PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 3114 E WEBER AVE 3"FL-STOCKTON CA 952( )09)468-3420 <br /> •>�NON-REFUNDABLE PERMIT CALL 209) .s-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> M <br /> JoBADDREss 33660 `A CITY/ZIP C Q m <br /> a <br /> A140,-- 131)c� ,-� ° <br /> (CROSS STREET 5�{ � APN/p3.S�.j��(9_��`_ L ''?-�tRCEL SIZE�LANDU EAPPLICATfION# - A <br /> OWNER NAME )iA LC C-e- Po. ` I �PHHO'NE,�/�` <br /> OWNERADDuEsS '-3 {//�'4 1CITYISTATEIZIP <br /> (CONTRACTOR I-V(.(C/�(�]/ f'J` tJN(/I�7I'_L`ti)/ �PPHOONEI�G� <br /> ,CONTRACTOR ADDRESS 1 `! M'1- f�7�P��.0 K(Y.• CITY/STATEfZIP /f'/L,CYf�r'�' _ �. •. _ <br /> SUBCONTRACTOR PHONE <br /> 'SUBCONTRACTOR ADDRESS //C''IT{pYISCATEIZIP <br /> LICENSE 7 ❑C-61 ❑D-09 ❑Other NUMBER/p FEXPIRATION DATE ZIJGyf <br /> GEOGRAPHICAL INFORMATION. Coordinates X Y Township Range Section <br /> INTENDED USE meslic/Privare D Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> { if different from Owner Water Systrm Name Coau,ct Name or Phone Number <br /> `{^{TYPE OF WORK few Well ❑Replacement Well ❑Well Alteration/Modification ❑Other 1 <br /> j D Monitoring Wells) #of wells ❑Soil Boring(,) a of borings ❑Geotechnical t'ortariags i" " <br /> ! ❑Out-Or-Scrvice Well ❑Out-Of--Service Well Renewal D Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair f <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Augei ❑Cable Tool ❑Push Paint ❑Other <br /> Proposed Well Depth,,Z_W ft Excavation Z,7 in diameter ❑Open Bottom ,ravel Pack I Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth 1� <br /> Well Casing Diameter In Thi tkn.s10.ugc/ASTM Sched� ❑Sted A<Iastic ❑Stainless Steel ❑Other. <br /> Grout Sea] Depth ft ❑Neat Cement(94 f6 bag/3-10 gal wafer} '❑0Sand Cement sack mix/7 gal water <br /> Mntooite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method mped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width n Length ft Thick in ❑Christy Bax ❑Stove Pipe <br /> PDMP- ❑Submersible ❑Turbine ❑Other HP Pump Sel ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> IOAQUIN 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 f AM IN COMPLIANCE WITH ALL ' <br /> WORKERS COMPENSATION LAWS. - <br /> MINIM�U}JM-24.24_PUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS �ry ry <br /> SIGNED Z D.. (e,2C'rL TITLE �w f`Ifor�r DATE '^. <br /> F 1 I Khs",Wk� <br /> r <br /> F� <br /> {o �N <br /> 4r <br /> pErpA TMENT USE ONLY <br /> F Application Accepted kIy Date 3 A' Area Employee[D# <br /> Grout Inspection By Date 4 ❑ SPECIAL Well Permit f <br /> Pump inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth it <br /> COM TS -1 <br /> PE SC Received hec AmounDate t Permits <br /> Codes Info Cash Remitted Service Request# <br /> 1 F' Invoice# Well 1D# <br /> 4wf '1�l zS�' 3 o 5 i s iID-A-213 <br /> E <br /> EMD 43-D-oD6 WELL PUMP PERMIT <br /> WW2D05 <br />