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VVELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232-(209)468-3420 <br /> 00N-REFUNDABLE PERMIT CALL <br /> CALL 209 953-7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED <br /> JOB mDDRESS (63V �I''a h R� Cr Y/ZIP Ma►tFtCg CR <br /> (.:ROSS STREET MOAAtGIL Rol•. APN 26-1 3'] PARCEL SIZE ID.00 LAND USE/A'PPLICATION# A <br /> OWNERIIAME C]_I_� SM ba,nj 't PHONE bj/l2--d I3/2 y <br /> OWNER.'DDRESS •V . 92 CIN/STATE/ZIP�T lA 157" <br /> CONTRACTOR T K . PHONE 522-tot ZS <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP J y <br /> eS I b i' CS 4 M <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE IleC-57 0 C-61 D D-09 0 Other NUMBER lm2z-- EXPIRATION DATE Li <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: water SySteM Narne on ac arae or Phone NUMber <br /> TYPE OF fJORK ew Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings 0 Geotechnical R of borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connectlon Repair <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> 'HELL CONSTRUCTION <br /> Drilling illethoc)Q Mud Rotary 0 Air Rotary D Auger 0 Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth 2.440 It Excavation in diameter 0 Open Bottom )(Gravel Paok/Gravel Size in diameter <br /> 0 Conductor Casing In diameter 1 Conductor Casing Depth ft <br /> Well Lasing Diameter in Thlckness/Geuge/ASTM Schad ZOO 0 Steel KPlasfic 0 Stalniess Steel 0 Other <br /> Grout Seal Depth O ft 0 Neat Cement(94 lb bag/5-10 gal water) 0 Sand Cement sack m1x/7 gal water <br /> (Bentonite(20%solids) 0 Other <br /> ,Grout.Placement Method XPumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller Kump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width It Length ft Thicic In 0 Christy Box 0 Stove Plpe <br /> PUMP 0 Submersible0 Turbine 0 Other HP Pump Set ft `Standing Water Level-I'Ll <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAOUIPI COUNT`( ORDINANCgS, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITM`THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT.1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQVIIRED FOR INSPECTIONS <br /> SIGNED T K DATE 7- <br /> .41 <br /> Is 11 1 <br /> IH O TY <br /> EA A <br /> LTI D Pil RT ME 4T <br /> D� ARTMENT PSE ONLY . <br /> Application Accepted By Dat Area Employee ID#A-e <br /> Grout Inspection By Data 'SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Borinf I spection By Date Constructed Well Depth It <br /> COMMENTS -2 19 <br /> PE Se Received Checic#/ Amount Date Permit] Invoice# Well IDifi <br /> Codes Info By Cash Remitted Service Request# <br /> W 00r3ggq-S <br /> i 3 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> a%o4M <br />