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WELL'/PUMP PERMIT - 094 �600 <br /> SAN 304014 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT; Y r - '600 EAST MAIN STREET STOCKTON CA 95202r (209)468 3420 <br /> NON REFUNDABLE PERMIT CALL 209 953 7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> o �,� -,,,, (/f <br /> • y JOB ADDRESS �/ % -'" iF/ �i/ /1'Ci CInIZIP !1 <br /> G <br /> CROSS STREET 1 0' 1 1!!l Fa hq APN PARCEL SIZE LAND USE APPLICATION# <br /> J N <br /> N <br /> OWNER NAME <br /> "L <br /> OWNER ADDRESS CITY/STATE/Z <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS r/ 1 ( '4 l b c,+.rr k<i x. J CInISTATE/ZIP n/i�i� J 7 7 4, <br /> a <br /> SUBCONTRACTOR <br /> } PHONE - - <br /> SUBCONTRACTOR ADDRESS ' CITY/STATE21P m L <br /> 1 C! i L Y �d d y•�/ r y' _ � � j�_ { <br /> 1 LICENSE C 57 ' D C 61 L,D 09 [1 Other <br /> I { NUMBER ..4:17 p{ yS EXPIRATION DATE,_..��t <br /> —' <br /> .-.="q„�+'+baom+'�7!' bio <br /> GEOGRAPHICAL INFORMATION COOrdlneteS X Y Township_ Range Section <br /> t <br /> INTENDED USE D Domesbc/Pnvate D Irrigation/Agricultural 0 Industnal 0 sWater Quality Monitoring 0 Sod Sampling/Charactenzahon; i <br /> �Pubhc�Water System <br /> t I'Ir d Here d from Ow s. er ys m me ,y Nam o ne um <br /> r.r r y <br /> °TYPE OF WORK 0 New Well �<ReplacemenYt Well C Well ARerationl odification 0 Other ' <br /> of bor <br /> 0 Monitoring Wells) #of wells 0 Sod Bonng(s) or do riga 0/Geotechnical ri )riga d v <br /> 0 Out-Of Service Well D Out-Of Service Well Renewal 0 Cross Connection Repair )} r <br /> I � <br /> 0 New Pum D Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well,,Depth J�70 —it Excavation f Z '1 in diameter 0 Open Bottom` �-,Grav_ellPack/Gravel Size ' in`diameter <br /> y <br /> r 0 Conductor Casing in diameter / Conductor Casing Depth ft n ? <br /> I Well Casing Diameter-10—ln Thickness/Gauge/ASTM Sched ..700 0 Steel �<Plasbc Cl Stainless Steel O Other^ J <br /> { r Grout Seal Depth raz 00'-r eft J 'D Neat cement(94 lb ba4/5!10 gal water) XSand Cement,%Ow S wr —sack mix/7 gal water, <br /> 4 . ❑Bentoniter(20/solids).`10 Other _ <br /> Grdijt Placement Method Pumped ❑Free Fall ❑Other " 0 Retardant!Accelerator(name)= <br /> l, E TAL Installed By 0 Dnller 9 }Pump Contractor—OJT Other, <br /> 0 Concrete,Pedesta)Dimensions Width ff Length(I 9 ft?hick in �0 Christy Boxy' 0 Stove Pipe I <br /> P P 1 0 Submersible❑Turbine 0 Other = HP_. _„Pump Set ft 1_Standing Water Level ft <br /> 1 I H REBY CERTIFY THAT I1,HAVE PREPARED THISk APPLICATION ANDyTHAT THE WORK WILL),BE DONE IN,ACCORDANCE WITH SAN <br /> �QQAQGIN'C UNTY ORDINANCES STATE LAWS AND;RULES AND REGULATIONS- I ALSO'CERTIFY THAWMY REQUIRED LICENSE IS <br /> liCURRENTy1DgACTIVEaWITH THE CALIFORNIA'CONTRACTORS STATE LICENSE BOARD AND"THAT£0 41N�COMPLIANCE WITHaLL <br /> WORKERS COMPENSATION"L'AWS'-='^- <br /> e ! MINIM/UM 24 HOUR ADVANCE NOTICE R�EQ41R+_ED FOR INSPECTIONS aq <br /> 1SIGNED, [( LV 11Z,3"f// TITLE 1 1+' 1 Ito" X� '."S .. �� DATE � ��y'•��� <br /> ti - a <br /> J' <br /> 1 <br /> ak L I I <br /> a s I r t I <br /> r e — i <br /> - v <br /> ( .0,EPARTMEN,T UISE ONLY r ^ <br /> P Application Accepted f}y� /J/ i ��`u f r if! E! N... Date J J� dlArea Employee ID# <br /> Date ❑ SPECIAL Well Permit <br /> Grout Inspection By a <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Sal onng Inspection By Date Constructed WeIllDepth - ` J ft <br /> d COMM SI��JBJ / > 1 F ( f l, r� ' <br /> 3 PE SC Received r Check#/ Amount+ 'Date ''PermiVt a r'4-4 # 'Invoice#v / Well ID# <br /> Codes Info 1B.a Cash Remitted r �... Service Re uest# <br /> f��/ r y <br /> h <br /> i <br /> WELL/PUMP PERMIT t <br /> EHD 43-06 `' r cl c 1 !i t, <br />