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v WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAW STREET-STOCKTON CA 95202-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> f �0 <br /> Joe ADDREas /636'0'�/-a k' I'c Cm2 � <br /> tP c�r� �j 5:;2`/C) D <br /> CROSS STREET T!a / APN 0SI—200-06p PARCEL SIZE LAND USE APPLICATION# <br /> ion <br /> OWNER NAME ai e/ PHONE 5 9 3•-1!- VI H <br /> OWNERADDRESS _ -+Lc.$ CmIISTATE/ZIP U <br /> CONTRACTOR --M o e., .tvdrJ t/Vb7"L' /JSks 1'Yr�J PHONE 97 a <br /> r--71 D <br /> V •1 <br /> CONTRACTOR ADDRESS I�O u tax, Ae CRY/STAT.MP <br /> SUBCONTRACTOR 4S r fV��,jyy /�� 3^ PHONE <br /> I SUBCONTRACTOR ADDRESS !I!Le <br /> CITYISTTATTE/LIP m /j'✓J I'D / <br /> LICENSE OC-57 ❑C-61 C D-09 C Other NUMBER d i 6 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> I INTENMO USE C DomestidPrivate 4 irrigation/Agricultural C Industrial ❑Water Quality Monitoring C Soil Sampling/Characterization <br /> i ❑Public Water System <br /> It different from Owner. , r em ame contwNameorPnone umber <br /> TYPE OF WORK #New Well C Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑MonitoringWells #of wells n Soll Bort t of borings rl of borings <br /> ( ) ng(s) ❑Geotechnical. <br /> ! O Out-Of-Service Well o Out-0f-Service Well Renewal C Cross-Connection Repair <br /> New Pump El Pump Replacement D Pump Repair C Raise Well Casing <br /> ' WELL CONSTRUCTION <br /> { Drilling Method f Mud ry ❑Alr Rotary ❑Auger C Cable Tool C Push Point C Other <br /> Proposed Well Depth YO ft Excavation In diameter C Open Bottom 4f Gravel Pack/Gravel Size in diameter <br /> C Conductor Casing — in diameter 1 Conductor Casing Depth — ft <br /> Well Casing Diameter_?_in Thidrness/Gauge/ASTM Sched 4C,16jj G Steel $Plastic D Stainless Steel O Other <br /> Grout Seal Depth !�-D ft a Neal Cement(94/b bag/5-10 gal water) o Sand Cement sack mbr/7 gal water <br /> )0 Bentonite(20%solids) C Other <br /> Grout Placement Method )(Pumped O Free Fail ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller )CPump Contractor C Other Z <br /> Cl Concrete Pedestal Dimensions:Width�_ft Length ft Thick in D Christy Box ❑Stove Pipe <br /> PUMP *SubmersibleC Turbine ❑Other HP Pump Set ft Standing Water Level //S� it �T <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MIN M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTI S-PLEASE CALL(209)953-7697 <br /> { SIGNED - TITLE DATE <br /> -G <br /> "�Iltl 11 <br /> ON UF%rr <br /> -12411- EnAF 71V zN <br /> ,r <br /> sAl ri- <br /> T �- <br /> s <br /> 2-6 3 - 6"yI incl;?!oONLY <br /> pplicaticn Accepted By Data L Area Employee ID# S 9 tF fjF qC� <br /> Grout Inspection 8 Date ❑ SPECIAL Well Permit <br /> Pump Inspection B - Date / ❑ WAIVER Received <br /> Soil Boring Inspection Sy Date Constructed Well Depth ft <br /> COMMENTS Zjr;t.�LG�I 11�74.= // -, azL�- Z)G60 <br /> PE Sc Received CheciW Amount PertniN <br /> Codes Info B s Remitted Date Service Request# Invoice# Well ID# <br /> *3l,5 t tV O taw 6¢oo&zz69 <br /> rf35r D os" S3• �Db(a 22 10 <br /> { END 43,06 WELL/PUMP PERMIT <br /> 6r26M <br />