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117 WELL/PUMP PERMIT <br /> 600 EAST MAIN STREET-STOCKTON CA 95202-(209)469-3420 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT i <br /> NOIEFUNDABLE PERMIT CALL(2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> w <br /> �,Y CITYIZIP G.t?b .. D <br /> i JOB ADDRESS - O <br /> CROSS STREET C.�/' APN O� DCOP <br /> 00 PARCEL SIZE�O LAND USE APPLICATION <br /> CS <br /> # T <br /> OWNER NAME a/) d�Qt S6N PHONE.7 S – 3O'3 D N <br /> OWNER ADDRESS CITYISTATE" <br /> PNONE 367– q7-LS <br /> CONTRACTOR ,nSWOO,,�.,h <br /> CONTRACTOR ADDRESS ,`� Crry/STATERIP WO <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYIST,.A.yTEEr/jp <br /> LICENSE I�.-57 0 C-6t 0 0-09 0 Other NUMBER'S773 EXPIRATION DATE �3 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE jgDomestic1private 0 Irrigation/Agricuttural ❑Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> O Public Water System <br /> tf dilferanr from Owner waw y em am a am or no umber <br /> TYPE OF WORK New Well O Replacement Well ❑Well Alteration/Modification 0 Other <br /> D Monitoring WellA of borings s) #of wells O Soil Boring{s) O Geotechnical n of borings <br /> O Out-OfSerVice Well 0 Out-Of-Service Well Renewal O Cross-Connectlon Repair <br /> .I9QJew Pum D Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CoNSTRuc-noN <br /> Drilling Method�tUd Rotary O Air Rotary O Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Weil Depth 1?0 —ft Excavation�1. in diameter 0 Open Bottom ,XGravel Pack/Gravel Size_In diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched Z as D Steel 'iXPlastic O Stainless Steel D Other <br /> Grout Seal Depth�—ft D Neat Cement(94 lb bag/5-10 gal water) *<Sand Cement �d sack mix17 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method WtPumped D Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 6mriller 0 Pump Contractor O Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick In Cl Christy Box O Stove Pipe <br /> PuuP _-R%ubmersible0 Turbine 0 Other HP Pump Set ft Standing Water Level ft \ <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN R <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 LAWS. \ <br /> Le�MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED //To-- TITLEDATE410 <br /> S O QL IN O <br /> EA TH D <br /> A P A R-T -N T S 9-0 N L Y ...A.�_ _. <br /> Application A ate6/ Area Employee ID# <br /> Grout Inspection to l 0 SPECIAL Well Permit <br /> - _ _ <br /> t Pump Inspectio. Date / ❑ WAIVER RCC6iv6d�' <br /> Soil Boring In ction By Date Constructed Well Depth It <br /> 4 COMMENTS _ <br /> /!7i/J/�1�is� � �?-/�/ Cly <br /> PE SC Received hec Amount Date PetmiU Invoice# Well ID# <br /> Info B Remitted Service Request# <br /> ►' 3s isoyi-ori s (oQ(0`71 <br /> o coo s as � 2ao <br />