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WELUPUMP PERMIT �(SZ�, IUoS ¢M�-1P-I- ROzoti�-StS��rzcs <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA95202-(209)468-3120 <br /> NON-REFUNDABLE PERMIT CALL 0209}953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> y <br /> JOB ADDRESS V W r ""' P� CI7Y12IP <br /> C, <br /> 7y'� (1 7 I� <br /> CROSS STREET IAV SSVn r" • #APN Z7 I B PARCEL SIZE'!Y'Z LANE)USE APPLICATION _ <br /> OWNER NAME G 'i -?il S7;e- /cs— PHONE <br /> OWNER ADDRESS CITYISTATEIZIP <br /> CONTRACTOR lUe,h •� _ PHONES+N <br /> C4�K i-17'w <br /> CONTRACTOR ADDRESS ?�`NI 4f74 m�rpprr iZC 3 StL � CIrY1STATrJZP ` i9�t C+T <br /> SUBCONTRACTOR �'CS/I+sr-<I)-�TJIL. PHONEC/®QST 3r3-ySBo� <br /> SUBCONTRACTORADDRESS z -r2` W�1A tnT �t�'• CITYISTATEMP 7`'Iticl tt�l C �J r5 f <br /> '35 <br /> LICENSE _ C-57 G C-61 C D-09 D Other _ NUMBER U) ILS E%PI RATION DATE l <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE ]DomesllclPnvate n IrrigationlAgricultural n industrial U Water Quality Monitoring Soil Sampling/Characlerizalion <br /> E Public Water System e Um er <br /> pr <br /> Rublic from Owner er ye ems e <br /> TYPE OF WORK ]New Well U Replacement Well U Well AllerationlModification n Other <br /> A of boMgs <br /> D Monitoring WellR m bongs s) A of wells ❑Soil Boring(s) )CGeotechnical ?Z <br /> U Out-Of-Service Well n Out-Of Service Well Renewal D Cross-Connection Repair <br /> L New Pump n Pump Replacement F Pump Repair. u Raise Well Casing <br /> I WELL CONSTRUCTION .� <br /> Drilling Method D Mud Rotary El Air Rotary G Auger YL <br /> Cable Tool xPush Point n Other <br /> Proposed Well Dept4o--eD(M—R Excavation I/L In diameter n Open Bottom Gravel Pack/Gravel Size in dlameler <br /> E Conductor Casing __In diameter 7 Conductor Casing Depth R <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched D Steel U Plastic D Stainless Steel n Other <br /> I Grout Seat Depth ft XNeat Cement(94 Ib hag/5-10 gat water) i Sand Cement ,- sack miA17 gal water <br /> E Benlonite(20%solids) n Other <br /> Grout Placement Method X Pumped C free Fall D Other E Retardant I Accelerator(name) <br /> PEDrsrAL installed By E Duller D Pump Contractor u Other T� <br /> U Concrete Pedestal Dimensions:Wldlh ft Length ftThic In D Christy Box U Stove Pipe <br /> PUMP C Submersible❑Turbine D Other HP Pump Set ft Standing Water Level Z= <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 1. <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 <br /> (�REQUIRED <br /> /FOR INSPECTIONS 7 <br /> SIGNED TmJe 1 N�P.G"F' C,,.,- t0Cr t Sf DATE I G I <br /> AP <br /> A; 1 1 <br /> P fit s II jfE!\rEt)' <br /> . .DEC 0'- <br /> DEPARTMENT -USSE ONLY <br /> , <br /> Application Accepted By _ Date —`t Area Employee ID# <br /> Grout Inspection By _. _ — Dale SPECIAL Well Permit / <br /> Pump Inspection By Date WAfVER Received <br /> Soil Boring Inspec nZBucted Wel Depthtr <br /> COMMENTS / ft <br /> PE SCReceived Check#! Amount Date PennlV Invoice# Well ID# <br /> Codes Into B Cash Remitted Service Request# _ <br /> "1-37 .so Gro l3?23 <br /> [HD4 08 V.fl L 1PUMP PERMIT <br /> ajQ4/o8 <br />