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WELL/PUMP PERMIT <br /> AN JOAcium COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS <f Ci1TY21P I—A 6 <br /> D <br /> 0/ r 0 <br /> APN �' ��" <br /> CROSS STREET �] PARCEL SIZE 4Z&D USE APPLICATION# <br /> OWNER NAME !� PHONE J Ye <br /> OWNER ADDRESS OO CITY/STATFJZIP <br /> CONTRACTOR 7� PHONE <br /> e2- l Zl <br /> CONTRACTOR ADDRESS /!/V �C CRY/STATE2IP <br /> I C� <br /> SUBCONTRACTOR J� PHONE �l <br /> SUBCONTRACTOR ADDRESS CRY/fSTATE21P C� <br /> LICENSE C-57 61 E3 D-09 ❑Other NUMBER_ r� �/U EXPIRATION DATE <br /> GEOGRAPHICAL INFORMA ON: Coordinates X Y Township_ Range Section— <br /> INTENDED <br /> ection_INTENDED USE ❑Domestic/Private ' nigation/Agricultural ❑Industrial ❑Water Quality Monitoring D Soil Sampling/Characterization <br /> OF Water Sys V�f <br /> neu <br /> Ifdlfferemfr°m Owner. em ame amen l <br /> TYPE OF WORK D New Well {Replacement Well ❑Well AlteratioNModification 13Other 11 <br /> 0MonitodngWell(s) #of wells ❑Soil Boring(s) xafb0°°� ❑Geotechnical ab0°D� <br /> a <br /> D Out-Of-Service Well ❑Out-Of-Service Well Renewal D Cross-Connection Repair <br /> ❑New Pum Pum Replacement ❑Pum Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑Air Rotary D Auger ❑Cable Tool ❑Push Point ❑ ODler u <br /> Proposed Well Depth_3SD ft Excavation/_in diameter ❑Open Bottom ravel PacklGravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter/0—in Thickness/Gauge/ASTM Schede/ ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth �� ft ❑Neat Cement(941b bag15-10 gal water) /❑Sand Cement sack marl gal water <br /> /entonite(20°h solids) ❑Other <br /> Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller XPump Contractor ❑ Other <br /> ❑Concrete Pedestal Di nslons:Width tt Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑ ubmersiWe❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> 1 HEREBY CER IFY 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 /> MIN U OUR ADVANCE NOTIC�UIRE/9 F0 INSPECTIONS �J �ry <br /> SIGN TITLE `S G�6�— DATE Ir/ Q/ <br /> i <br /> G � <br /> tr <br /> -:i / 3 - <br /> .. I <br /> G <br /> d <br /> Z is <br /> Application Accepted Date U�D Y Area oa l / Employee 10# 7 <br /> Grout Inspection B ^ c i" —J Date /� ❑ SPECIAL Well Permit <br /> Pump Inspec' _ Date /�/G/ ❑ WAIVER Received <br /> Soil Badng Inspection B Date Constructed Well Depth it <br /> COMMENTS Zl� f ' ' I�/il - <br /> PE SC Received Check#( Amount PermiU <br /> Codes I Info By Remitted Date Service Request# Invoice# Well ION <br /> oS� Sa" 1U oo a 9 1/ <br /> EHD13-05 � �.7/I[�(�I/ - ZZO`7t7j/�'9CEC-f'CG:e/ �t,7.r✓(��i'I-t.f�= 7YY�' <br /> ELL/PUMP PERMIT <br /> B104)0B 1 <br />