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WELUPUMP PERMIT 146r;-1 oclo <br /> ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT bob EAST MAIN STREET-STOCKTON CA 95292-(209)468.3420 <br /> NON-REFUNDABLE PERMIT C Lt 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Tr4 I D <br /> JOB ADDRESSHWY rCb mM✓ ITY/ZJP L(;:,Lam` <br /> d�'^ n�pyo OSS t OI i v <br /> CROSSSTREET e IJArr&D a0i'T-J APpN�?L"S,-i-91c>c>A PARCEL SLZC_% ANO USE.A�PPP.LIICCATIIO�N## �{ y m <br /> OWNER NAME �j A�T`t T cAt,1 M(zN J P,1�j���j� PHONE Z 4 T T�p r0' l <br /> OWNER ADDRESS Z 3t�l^, 1514Q1418414-6 i Cm/STATE7LP S_jX 'ON CTS-ZI VQ <br /> CONTRACTOR is K— / 'Ss it`^�7 CS ren s1J r PpH�ONUE�q j L—99?--!jZ-(l�[3 <br /> ' CONTRACTOR ADDRESS <br /> �pf31+2 -4 gV Lt42 Ud'{�I_ P DR- /7T�6 IGD �CCrTYISTATE0P <br /> SUBCONTRACTOR CA LI F0�PV�I�Pt PY S,CT r [-�1-H/LV 0Li/.�7I G.] tP�HfONE{��p tO��p��t®Q��� <br /> SUBCONTRACTOR ADDRESS 104-CONST I TLA Y10M Mile sT t2 Ctrv;jT.•,,,.�ja;P MLJv L.0 PAII!,�+�CA'1 a402� <br /> ' -' 0q wl <br /> LICENSE G57 �.,C-61 � D-09 :Other NUMBL•R' EXPIRATION LATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED LrSE 7 DomesficJPdvate .-i IrrigationlAgricultural C industrials __Water Quality Monitoring o0 SamplinglCharaCterization <br /> 7 Public Water System <br /> Nubli ent hom Oyste Water SYSI.. ams a ame or one um r <br /> TYPE OF WORK New Well Replacement Well f-Well Alteration/Modification =Other C IT <br /> tl of boon <br /> Monitoring Well(s) #elwells �iI Bora+g(s) Motborirlgs XGeotechn?cal 7 � <br /> 7 Out-Of-Service Well -Out-Of-Service Well Renewal C Cross-Connection Repair <br /> 7 New Pump J Pump Replacement J Pump Repair C'Raise Well Casing . <br /> WELLC.UNSrRUG11011 I !1 <br /> Drilling Method !Mud Rotary 7 Air Rotary L Auger Cable Tool D Push Point 7 Other <br /> Proposed Well Depth 4S-3-b It Excavafion__-+ in diameter r Open Bodom 0 Gravel Pack/Gravel Size in diameter <br /> i Conductor Casing in diameter 7 Conductor Casing Depth ft <br /> Well Casing DiamelerwAIn ThickneWGauge/ASTM Sched ❑Sleel O Plastic C Stainless Steel D Other <br /> Grout Seal Depth ft Neat Cement(94!b bag/5-10 gaf water) r Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) 7 Other <br /> Grout Placement Method u Pumped L Free Fall Other -j Retardant 1 Accelerator(name) <br /> nPE M& Installed By 0 Driller G Pump Contractor �i Other ' <br /> 7 Concrete Pedestal Dimensions:Width R Length ft Thick in C Christy Box 0 Stove Pipe <br /> PUMP 7 SuhmersibieC Turbine 17 Other HP Pump Set R Standing Water Level ft <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 NTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AN IN COMPLIANCE WITH ALL � <br /> WORKERS COMPENSATION LAWS. ® a <br /> NAI iMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED c�lGot'ldt.At r4 *17,4101 <br /> t <br /> tOfInq <br /> Lj <br /> Is <br /> C) ul q,77o <br /> DEPA TMENNIT US ONL <br /> Applic anon Accepted B .tate `Z ©r Area Employee IDvr <br /> Grout Inspects rI 6 .2 ate_ /T9_ SPECIAL Well Permit. <br /> ' Pump Inspe 'on Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> ' COMMENTS — <br /> PE SC I ReceivedAmount Permit! <br /> Codes Into B Cash Remitted D to Service Request# Invoice# Well tD# <br /> EHD 93-05 WELL.PUMP PERMfr <br /> tB/Q4/a8 <br />