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WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FI.-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL-(209)9S3-7697 FOR INSPECTIONS EXPIRES S YEAR FROM DATE ISSUED <br /> i y <br /> J4BAUDRFSS1 3 Aj _ CITY/ZEP /r�./ISN <br /> CROS.SSTRFET i�!)��"f /--t .. <br /> AP �T �•0` PARyCEL SIZE ryry�7'� <br /> OWNERNAMP, �ILiYL�`-/'� �[lN ��1 _ PHONE'_/�`e�~�// ``_ , <br /> OWNER'ADURMS '� 5 !� CITYISTATEIZIP /'T T c� `g <br /> CONTRACTORi/��I�{,7 TJ�� _ _ _ - / PHONE -,�q7✓�r / t!� <br /> CONTRnCfORADORLS:" -'tiy^"' J'V 1F�+�I/L --' 0TWSTATElZIP ?Fjj1teQFAoji�� <br /> SUDCONTRACTOR PHONE ~1 <br /> SIDCONTRACTOR ADDRF_CS_ CITYISTATEMF <br /> LICENSE 0 C-57 0 C-61 C D-1:19 0 Other _ _ _ N <br /> NUMRP.R&M-5­2- EXPIRATION DATE: �I Q <br /> GEOGRAPHICAL INFORM&TION: Coordinates X V Township Range Sectian <br /> ISTUNUED USE omesliC/Private Q lrrigalionlAgricuhural L7 Industrial 0 Water Quahi ,Monitoring 0 Soil Sampliog/Churacterization <br /> 0 Public Water system <br /> If diffrrant tram Dnvtt, W.W yuem gine 4---E..o7n`scl.neo: on-Nu r <br /> TYPE OF WORK 0 New Well ❑Replacement Well ❑Well AlteralionlModification 0 Test Hole (3 Other <br /> nwnber arwdll number oftio".1" camber of swags <br /> ❑Monitoring Well(s) � C3 Soil Borings} OCeoeechnical <br /> R Wcll Destrucrioo ❑put-Of-Service Well 0 Out-Of-Service well Renewal <br /> I 0 New Pump )!f?ymp Re la=ement 0 Pump Repair 0 Cross-Contimtion Repair <br /> WELL CONSrRLCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary ❑Auger 0 Cable Tool 0 Push Poini 0 Other <br /> Prnpnsed Well Depth 4 Excavation in diameter Cl Open Bottom E]Gravel Pack!Gravel Six in diameter <br /> 0 Conductor Casing _in diaMC(CT f Conductor Casing Depth tl <br /> Well Casing Diameter_in Thickness/Gauge(ASTM Scholl 1.2 Slee! 0 Mastic 0 Stainless Steel ❑Other <br /> Grout Seal Depth 11 ❑Neat Cement(441h hug/3-10gal weer) ❑Sand Cement ,rack mix 17 gal water <br /> 0 Bentonite(2D'/v solids) 0 Manufacture:Spec%solids %" Name O Specs on File 0 Specs Submitted <br /> Grout Placement Mel had O Pumpcd O Free Fall D Other 13 Retardant I Accelerator(name) <br /> PEDESTAL nstaHed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pvrlesral Dimensions: Width fl Length R Thick in 0 Christy Box 0 Slove Pipe <br /> PUMP PYSubmersihle ❑Turbine 0 Other HP Pump Set k4'] rt Standing Water Level_� ft. <br /> WELL DESTRUCTION 0 Open Bottom 0 Gravel Pack 0 Uncased ❑Other <br /> Well Diameter in Total Depth 11 Depth to Water 11 ❑Casing to he Perforated tiom R to R <br /> Searing Material 0 Neat Cement(9416 hag/3.10gal rwrree) O Sand Cement sack mix/7 gat water 0 Bcnumite Pellets <br /> El Bentoniie(201%solids) ❑Manufactvrer Spec%rolidR__% Name O Specs on File ❑Specs Submitted <br /> i Placement Method 0 Pumped ❑Free Fall 0 Other <br /> ❑C:ompWc with Mushroom Cap 11 below grade O Complete to Existing Sufraee Pad <br /> 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. 1 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 LA 'S. <br /> M, M 24 DVANCE NOTICE RLQUIRED FOR IN P CTIONS—PLEASE CALL(209k)953-7697 <br /> SIGNED '� .�-f irLEDAT¢ <br /> J <br /> 4 <br /> 0 <br /> ULIC .b T1 7M <br /> jTW Pkko', {'V <br /> p, <br /> VIM 4 <br /> =USE ONLY py <br /> Application Accepted By Date 07�Z�. Area I$ $mpleyer-IDk 7 .� <br /> Craut lnspcotisnBy Date 13SPECIAL Well Permit <br /> Pump Inspection flY Dalt O Q WAIVER ReCeIVeij <br /> I Vesrrucrion Inspc elion Sy Date Constructed Well Depth If <br /> COMMENTS <br /> PE SC Received Check#/ Amount Dale PerrlItt Invoice# Well IM, <br /> Codes Info R as Remitted ServiceR uest# <br /> lzixa 40 <br /> EFID43-02-066 MASTER WATER WE LI,PERMIT <br /> ]2l612t)02 <br />