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ELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA NT 600 EAST MAIN STT-STOCKTON CA 95202 - (209)468.3420 <br /> NON-REFUNDAD!c DcpMIT - 1909) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS (26lJ INav <Ct9�'r-. 1''1,r. '^ n CITY/ZIP��L.T(y� r^ <br /> CROSS STREET ✓�/QS /" yj APN J 70361 PARCEL SIZE NAG- LAND USE APP\\LIICCA(�TION# <br /> rn <br /> Y- 6'f LfCM PHONE-�61) t3.- C"2- �•' <br /> OWNER NAME �IyIU S/F/ <br /> OWNER ADDRESS 3o/) Nn✓• of. CITY/STATEIZIP <br /> C � <br /> CONTRACTOR I r�rLvAt <br /> e lA7(f t%S'r drr [ � <br /> &4 kJ1 L d. PHONES/0 dL sd-3-Lao I7� /p// <br /> CONTRACTOR ADDRESS LW3 li/.1 r7NY1//'[�C t-ee CITYISTATEIZIP / 4 Glr<<�l/ / I7J 7 — <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYICSTgV AT�EIZIP <br /> ❑ J / <br /> LICENSE C-57 C-61 ❑ D-09 ❑ Other / NUMBER ) - y� -�>- EXPIRATION DATE /� 1 <br /> GEOGRAPHICAL INFORMATION: Coordinates �c22- Y /7-126-�65 — Township_ Range_ Section _ <br /> INTENDED USE ❑ DomestidPdvate ❑ Irrigation/Agricultural AtIndustrial ❑ Water Quality Monitoring ❑ Soil Sampling/Charactedzafion <br /> ❑ Public Water System <br /> If different from Owner. Water Ystern Nam ntaCt Name or Phone Number <br /> TYPE OF WORK t�i-New Well ❑ Replacement Well ❑ Well Nteration/Modification 9(Othar 6 ro is <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) not bodngs D Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> d� <br /> Proposed Well Depth Y S ,t Excavation in diameter ❑ Open Bottom^ ❑ Gravel Pack/Gravel Size I, in diameter <br /> p/Conductor Casing_r Win diameter / Conductor Casing Depth—a] it <br /> Well Casing Diameter F" in Thidmess/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft jtNeat Ceme/;�t//1!94/6pp,yyag/5-10 gal water) ❑ Sand Cement s/ack mix/7 gal water <br /> ❑ Bentonite(20%solids) Other ��/T? ✓{yru <br /> Grout Placement Method XPumped ❑ Free Fall ❑ Other V Retardant/Accelerator(name) <br /> PEDESTAL // Installed By ❑ Driller ❑ Pump Contractor ❑ Other r <br /> Atx ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible Turbine ❑ Other HP Pump Set ft 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209) 953-7697 <br /> SIGNE9 TITLE Pre,;red �"t aN4 S 1✓' DATE 7' <br /> / � �� DEPARTMENT USE ONLY <br /> Application Accepted By 1416 `mi`''l Date ���YI ZO I I Area Employee ID#�_ <br /> Grout Inspection ByDate ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By_ ,I I Date Constructed Well Depth 2-7.5 ft <br /> COMMENTS a-APAA ✓,-� /V!( k,`,/ 3 = P_'11S .ea C'A-7-AklyL' <br /> PE SC Received Check#/ Amount Date PermlU Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re Date # <br /> a461x1 IZZ 4l 2-7I � G//yToa G�? / <br /> 1903 1�S !�K <br /> 17-71 P 1 <br /> &q o5 2u� l� I OSl8�T2 <br /> E6109 6 � ®�� WELL/PUMP PERMIT <br /> HD 4 (IX <br />