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WELL/PUMP PERMIT ." L 6/,3Q�'G�S <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3'°FL-STOCKTON CA 95202-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR I%SPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED N <br /> _a <br /> MlLAA if) f-�p;.✓1Q D, 1 L c, {�CRv/ZIP M ,4,,4r,iq �a�✓1�- <br /> JOB ADDRESS a 3 Ste, -�z T i <br /> 0 <br /> 1 I 4 PARCEL SIZE AND USE APPLICATION# <br /> CROSS STREET1^^'// � IAPN\?6 rl—nun—�h <br /> OWNER NAME YQL1 �� LA <• -�'✓�% 111-��� ` '� PHONE <br /> OWNER ADDRESS CITY/STATFJZIP <br /> CONTRACTOR ! : I� I✓1 C PHONE /'-� <br /> (� CITY/STATFJZiP y f(43a V� <br /> CONTRACTOR ADDRESS 7� / \ O�e,—(3 4 ` <br /> L�7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER lxzExPIRATION DATE Q-v <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE ingChaazacl ❑Water Monoring Sil Samr <br /> tion <br /> ❑Public Water System nwi oor one m <br /> If diffcrmrfrom Owns: attt yetem ame <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modificationp of❑Other p of 6odngs <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) h�Geotcchnical�. — <br /> ❑OutOf-Service Well ❑Out-0f-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger el 11 Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation L; diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cemrnt(94 lb bag/S-/0 gal water) ❑Sand Cement sack mix/7 gal water <br /> 11 Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name td. .dOt' Spxs on File ❑Specs Submitted <br /> Grout Placement Method El Pumped ❑Fra Fall ❑Other ❑Retardant/Accelerator(na e) <br /> D AL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> 13Concrete Pedestal Dimensions:Width It Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set It Standing Water Level ft <br /> 1 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 /> MINIMU 24 UR ADVANCE NOTICE REQUIRE FOR INCSPECTI S <br /> SIGNED17T5nL:21!e== <br /> TITLE /�( `I�fIL-� DATE ! V <br /> SA q J A UI 4 O <br /> ------------- <br /> nao <br /> DEP R T M E N T USE ONLY <br /> Application Accepted By Date Area Employee ID# -' <br /> Grout Inspection By Date *?""/O� ❑ SPECIAL Well Permit <br /> Pump Inspection By <br /> Date ❑ WAIVER Received <br /> Constructed Well Depth h <br /> COMMENTS�� /I,�fyilGf/ djf �� C-g Lg A�?tzf : C <br /> c ht/ 0 h6eg di i Il�f <br /> PE SC Received Check# Amount Date Peru Invoice# Well ID# <br /> Codes Into B as Remitted Service Request <br /> # <br /> 2 S� C- 12 ` s D6 S , akin <br /> WELL 11111 PERMIT <br /> EHD 43-02-006 <br /> laln0c5 <br />