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WELL/PUMP PERMIT <br /> SAN JoActum COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)4683420 <br /> 'NON-REFUNDABLE PERMIT CALL(209)9_53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 57 <br /> �l,� .__y� f Y <br /> JOB ADDRESS CITYILP <br /> y� ,/� at oD <br /> CROSS STREET ` .V k%\EJ 1 _� (_��APN �__l_1.49:: PARCEL SIZE LAND USE APPLICATION B m <br /> OWNER NAME `VT�sm 1L�(yQy�L�,jJ/��t} PHONE ( 6+�rq(�33'C `� <br /> OWNER ADDRESS ! 1 uT .11 1N C?\ G ___ CITYISTATEIZJP �10��C� �F' <br /> CONTRACTOR �1V%sr6,1 V a k, PHONE <br /> (CONTRACTOR <br /> CONTRACTOR ADDRESS 12j", �CiTYJSTATVZP (ek! ►1f, <br /> SUBCONTRACTOR ►�! - _- PHONE <br /> SUBCONTRACTOR ADDRESS N/ _ CITYISTATEMP <br /> LICENSE C-57 )<C-61 C D-09 C Other NUMBER t EXPIRATION DATE (' <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Ranga Section_ <br /> INTENDED USE omestc/Private E Irrigation/Agricultural _ Industrial -Water Quality Monitoring D Soil Sampling/Characterization <br /> L: Water r System <br /> R dblic Watt Owner waw system Name uontad Nam or Phone Number y]p� <br /> TYPE OF WORK New Well = Replacement Well C Well AfterationlModification D Otlter ` <br /> C Monitoring Well(s) Aof wells Soil Boring(s) Sof boring Geotechnical roi bonnpa <br /> Out-Of-Service - Out-Of-Service Well Renewal O Cross-Connection Repair <br /> New Pump ump Replacement Pump Repair I Raise Well Casing - <br /> WELLCONSTRUCTON <br /> I <br /> Drilling Moutod L Mud Rotary C Air Rotary 11 Auger a Cable Tool 3 Push Point C Other <br /> Proposed Well Depth ft Excavation- <br /> in diameter E Open Bottom C Gravel Par k/Gravel Size in diameter - <br /> Conductor Casing in diameter I Conductor Casing Depth fl <br /> , <br /> Well Casing Diameter_in Thidmess/GaugeJASIM Soled ❑Steel :1 Plastic I. Stainless Steel C Other <br /> Grout Seal Depth ft ._ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixlf gal water <br /> u Bentonite(20%solids) Other <br /> (Grout Placement Method - Pumped Free Fall E Other Retardant)Accelerator(name) <br /> �iPEDESTAL Installed By ,I Driller I I Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> ;,PUMP y ubmersible=Turbine _: Other__ HP ,� Pump Setft 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM FOUR ADVANCE NOTICE RRt2WiREDFR INSPECTIONS �r��/D <br /> $IGNE� TITLE DATE <br /> k <br /> 10 <br /> -,r <br /> S o <br /> D1 13 71 <br /> EPART ENT USANLY F C <br /> Application Accepted By _ Date ; 6 l Q Area Employee IDA ' ��� r/4� <br /> Grout Inspection 14— Date SPECIAL Well PetTnit <br /> Pump Inspection; 4+r� y " �'1 Date /,3 / WAIVER Received <br /> Soil Boring I�` .r�joj By Date Constructed Well Depth n <br /> COWENI /�l CC VA <br /> PE SC Received CheefcW Amount PermW <br /> Codes info B Remitted Dam Service Re uest A Invoice# Well ID# <br /> �3.-, 0­�rfl agg s -s�_�� 1 S12-00 S"77 - <br /> I 1 _ <br /> -- - - yyELL,9UMP PERMIT <br /> EHJ 41-0 <br /> 5/04A'A <br />