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' WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AV¢3'tl FL-STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> fin( LC //��� /�1/ tu) /�y1 (y/ /,fir <br /> JOB ADDRESS ( ,5r-7©O 5 r� - �`•'I err�I� CITY/ZIP �Z•C 1 � Cl/ <br /> �y �j'�j o <br /> CROSS STREET {�/{� �//Q APN y///r^�P✓,y "/' O�ARCEL SIZE LAND USE APPLICATITION# /' Q <br /> lrl.00 I ����� �/`�•ll�✓ PHONE <br /> OWNER NAME � <br /> �3�t� D�G1rr7�� 4Dt2 _ <br /> OWNERADDRPSS /.CCOITY/STATFJZIP <br /> CONTRACTOR 1ts W�/� �n,I' ��/yJ�` Y/K /�G PHO.N/F. <br /> 0�1 W (i(J�Ilt�t� C"'' �'U ' ^ C[TY'/STATFILIP�l`�N'�'L��- C • • / <br /> CONTRACTOR ADURESS _ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS - Cm•/STATEIZIP <br /> LICENSE C-57 ❑C-61 Cl D-09, ❑Other NUMBER�,Z ExPIRATION DATE©- —31— <br /> OJ <br /> GEOCRAPHICALINFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE ❑DomCalie/Private U Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> IoPubie Water S6=jSW_/1.GAul n9 Ou <br /> . <br /> fitffronr nmr <br /> TYPE OF WORK 0 New Well ❑Replacement Well ❑Well Alteration/ModificalionMol 0 other <br /> s orho�ng: <br /> {{{ ❑Monitoring WCII(s) #of wells ❑Soil Borings) ❑Geotechnical <br /> ❑Out-Of-Semcc Well ❑Out-Of-Scmice Well Renewal ❑Cross.Connection Repair O <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> iWELL CONSTRUCTION <br /> Drilling Method 10 Mud Rola ❑Air Rotary ❑Auger ❑Cable Tool 13Push Point ❑Other N <br /> Proposed Well Depth AOA11 Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> to be defcP,(csr/❑Conductor Casing in diameter / Conductor Casing Depth R <br /> Well_Casing Diameter Gm Thickness/Gauge/ASTM Sched 1,59- E Steel ❑Plastic ❑Stainless Steel ❑Other <br /> I Grout Seal Depth A ■Neat Cement(94/b bug/5-10gal water) ❑Sand Cement sack mix 17 gal water <br /> - ❑Bentonite solids) ❑Manufacturer Spa%solids % Name ❑Spas on File ❑Specs Submitted <br /> Croat Placement Method Y Pumped ❑Free Fall 13 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Inst■fled By ❑Driller ❑Pump Contractor ❑ Other <br /> 1 Coaerele Pedestal Dimensions:Width it Length fl Thick in ❑Christy Bos ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set R R <br /> Standing water Level <br /> 1 HEREBY_CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> I JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS.- 1'ALSO CERTIFY THAT MV REQUIRED LICENSE IS <br /> I CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HO ADVANCE NOTICE RE/QUIRED FOR INSPECTIONS <br /> SIGNED -' '�iI TITLE 1 _P DATE D <br /> 1 <br /> At <br /> I <br /> I <br /> I <br /> 1 <br /> N <br /> l 0 <br /> - DEPARTMENT U 'E O LY �Iq9 <br /> } <br /> �t ✓ <br /> Date 4L A. Employee ID#3L <br /> /Constructed <br /> ,.plication•Acceptcd Byy/ Data ❑ SPECIAL Well Permit <br /> rr ` Date - 13WAIVER Received <br /> Punj "nspection By WellDepth —17� ft <br /> "COMMENTS G Ia �u r <br /> 4, FF, S Received: Amount ern Invoice# Well ID# <br /> Codes Info B ash Remittedate,C Service ueN N. <br /> { w. •- <br />