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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazolton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 'JOB ADDRESS � (� C m C � ( � ,g Sin-, clTYrnP S i2 I S D <br /> J 1 0 <br /> CROSS STREET LI APN l�4 U f C 13 PARCEL SIZE Z LAND USE APPLICATION# a <br /> j N <br /> OWNER NAME ---If( .`^�` "� �.y� [�•�� PHONE j y <br /> OWNER ADDRESS / ('q)-vy�,f_ CITYISTATEIZIP! � ty <br /> /} p� <br /> CONTRACTOR L� �j• (/J\ �^ � LP/)HONE 2 0((- q1C -r�o <br /> CONTRACTOR ADDRESS .� L�V - - r L, G'7 CITY/STATE/ZIP Jr q f 3J <br /> SUBCONTRACTOR _ _ PHONE <br /> I <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D•09 Othef NUMBER O EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE DomestlGPrivate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Charactenzation <br /> Public Water System <br /> If ddrerenl from Owner Water Sytitent NOM Gonled.ame a onn N-- <br /> TYPE <br /> u•—TYPE OF WORK New Well Replacement Well _Well Alterition/ModificationOther <br /> Monitoring Well(s) #of wells Soil Boring(s) n°I:.05 _ Geotechnical x of borngs <br /> xAut-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump _ _Pump Replacement Pump Repair Raise Well Casing <br /> -i WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Ac Rotary Auger Cable Tool _ Push Point Other <br /> Proposed Wel) Depth ft Excavation In diameter - Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter ! Conductor Casing Depth ft <br /> Well Casing D-ameler_;n Thickness/Gauge/ASTM Schad Steel _ Plastic Stainless Steel Other <br /> Grout Seal Depth It Neat Cement(94 Ib bag/5.10 gal water) Sand Cement sack nrrx/7 gal water <br /> Benton to(20%solids) Other <br /> Grout Placement Method Pumped - Free Fail Other Retardam/Accelerator(name) -) <br /> i PEDESTAL Installed By Driller Pump Con:rac:or Other <br /> Concrete Pedestal Dimensions:Width It Length It Thick in Christy Box Stove Pipe <br /> PUMP _ _Submersible Turbine Other HP Pump Set It 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. 1 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 COMPS SATION WS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS / <br /> SIGNED TITLE '-�l.//� '-x, Ac'✓ DATE l0 L(-12- <br /> I <br /> -1L <br /> ` 111 -� <br /> - _ e <br /> WE a. <br /> ._ <br /> i <br /> — <br /> �— - - - <br /> ` DEPARTMENT USE O{JLY i <br /> Application Accepted y__ Date �O �F//� � Area Employee Employee IDN CSO l'e <br /> Grout Inspection / \ Dale SPECIAL Well Permit <br /> Pump Inspection Date WAIVER Received <br /> Soil Bonng Inspection By /J Date /1_ Constructed Well Death ft <br /> COMMENTS--..�-- -fC-I�a"11-r1L/c� --►�7�(.���tar°r PRo S y3�-? <br /> PE Sc Received Check#I Amount Permit/ <br /> Codes Info B Cash Remitted Date Servico r uest# Invoice# Well ID# <br /> E-1C<3-06 /� 'tel A.+�,7 ��• /1 ��L/� �,t, j,L,L.l.�CJ�Vj�j-�IJQ LL iPUMPPERM.. <br />