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)vim <br /> WELL/PUMP PERMIT <br /> SAN JoAOUIN CouNTY ENmoNMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 'zz5��Joo 0• S-4rLI&sNT AVf::. CITY2JP j-OrIR' <br /> CROSS STREET-..-_-TVe" A-D _APNV71'O70•08 PARCEL SIZE )(� LAND USE APPLICATION# <br /> f�i�ue.SI <br /> OWNER NAME -Lr IUYI l Lc- PHONE <br /> �- �l c_ j, <br /> OWNERADDRESS •7O � C,IITYY/.STATEMP LodU O/es Q 4 <br /> 0 <br /> CONTRACTOR K�N OeASON &550 C4 bVG' PHONE V'a-3/0 -3101 <br /> CONTRACTOR ADDRESS 'q -r-N 0 k ST" CITYISTATEMPCA - !J �Q <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/LP <br /> LICENSE C-57 C$1 D-09 Other NumISERbAgLO-0-4 EXPIRATION DATE <br /> GEOGRAPHICAL WORMATIoN: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE lomestic/Private Irrigation/Agricultural Industrial Water Quality Monitoringi Samp Ing a n <br /> Public Water System <br /> If ditrererd from Owner p m eme amc or one u <br /> TYPE OF WORK New Well Replacement Well Well Alteration/KWification Other <br /> Monitoring We 9(s) #of wells Soil Boring(s) a of bor'gs <br /> Geotechnical 1 <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 CoNSTRucnoN - <br /> Drilling Method Mud Rotary Air Rolary <u:;D Cagle Tool Push Point Other <br /> Proposed Wolf Depth5—15It Excavabon. — in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter_-in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth fl Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack fifiix/7 gal water <br /> Bentonite(20%solids) Other!%0#L- IN4rS I 140LE PLU =F W <br /> Grout Placement Method Pumped ree Fa Other etardant/Accelerator(name) <br /> Installed By Driller Pump Contractor <br /> Concrete Padests)Dimensions:Width engih ft Thick in Christy Box Stove Pipe <br /> PuYP Submersible Turbine Other HP Pump Set--ft Standing Water Level _R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS AppucATIoPrAND 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 IINNSPE�tCTIIONSJ ( l <br /> SIGNED �✓ _... TITLE ("j ELT M.41-A4 C-/'ATE <br /> n <br /> s, <br /> v . 4 <br /> Al <br /> -- <br />