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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468 3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS ��/ F YANat ��Jq(/�----- Cm/ ip LUAI "LII�/"�_ 6Qy <br /> CROSS STREET I� .-Cu 11 APN O� o <br /> � 0�aPARCEL SIZE 1I v LAND USE APPCATION# a <br /> OWNER NAME PHONE <br /> OWNER ADDRESS )1l CrTY1STATE/27P <br /> CONTRACTOR y�(�fIV Vt�r I 11 Y Irl PHONE ���Q �2� 1 <br /> CONTRACTOR ADDREss�•� IIX Crry/STATEIZi_tg3It 1'NJJ� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS .__. CRY/STATEMP ?1 <br /> LICENSE XC-57 C-61 D-09 Other NUMBERX383 EIwIRAnoN DATE-7-31-1 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic(Private Irrigation/Agricultural Industrial Water Duality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> it diflerertl ft—Owner r Sst— o— o ame or Phone um <br /> TYPE OF WORK r New Well Replacement Well L Well AlterationlModification Other <br /> MonitoringWell(s) #of weds I SoilBodng(s) #olbnrgs Geotechnical 0erboorgs <br /> Out-Of-Service Well I Out-Of-Service Well Renewal Cmss-Connection Repair <br /> New Pump Pump Replacement C Pump Repair Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method x Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth S?t it Excavation ,L-in diameter Open Bottom X Gravel Pack/Gravel Size_/ in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter�in Thickness/Gauge/ASTM Schede Steei x Plastic Stainless Steel __Other <br /> Grout Seal Depth I_ft Neat Cement(94 1b Dag/1-10 gal water) jf,Sand Cement sack mz/7 gal Water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method k Pumped Free Fall Other a Retardant I Accelerator(name) <br /> PEDESTAL Installed By Wnller Pump Contractor Other <br /> Concrete Pbdestal Dimensions Width__S_It Length---Z—it Thick_��in Christy Box P Stove Pipe <br /> -Ej <br /> PUMP Submersible Turbine Other HP Pump Set it Standing Water Level R <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> � ` TI SIGNED T 5 <br /> j"I P0 <br /> - s, <br /> Z W N L) - c - <br /> W > Z v - - <br /> LL, <br /> ca- a�c <br /> QW LU C Y <br /> CL a: <br /> r DEPARTMENT USE ONLY <br /> Application Accepted 8 Date Area o4 Employee 1D1'CS TS <br /> Grout Inspectlo Date 6 -1 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By_ Date Constructed Well Depth --n <br /> COMMENTS�4,— LLL-`, -� L '�L�I - - <br /> PE SC Revived Check#/ Amount Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Data Service Request# <br /> cl T? q( SlZDD 7-31 95 <br /> �nJ oS t3 (s SW CC-73(4 <br /> EMD43-0B ----- WELL rPUMP PERMIT <br /> V30112 <br />