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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95102-(209)468.3420 <br /> NON-REFUNDABLE PERMIT <br /> �7 _ C�A±LL 203 953-7n69YYyFOR INSPECTIONS EX�PI�tRES/�1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS -7019 / E. PFL-T/C+� 7W. CrTY2t,. 46AMPO / ls­7iso <br /> D <br /> �W 7'1^( b <br /> CROSS STREET_ 'L��••/eD• APN COS"��` IJ PARCEL SQP (LAND USE APPLICATION# m <br /> OWNER NAME ^IYam+G yMS �• C,� PHONE 136-7- +C,6V <br /> OWNER ADDRESS ?a%'I F+• �GCr1jF4_-I �fl/L . CrTYISTATEIZIP_�yT�00 4A f •J `'", r`~ <br /> CONTRACTOR _ A 16 6. �ry Iters SG e-. F jr4c• PHONE,6�) <br /> CONTRACTOR ADDRESS 7 Z /itM US 7-12,6+1wAY CITYISTATETZIP e_"/v�. <br /> l <br /> SUBCONTRACTOR ,%` I-J PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZJP C <br /> LICENSE xG57 U C-61 '_j D-09 J Other NUMBER 4 6 • EXPIRATION DATE 0 L It'l A <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDEDUSE C DomesticlPdvate _r Irrigation/Agricultural Industrial Water Quality Monitoring A Soil SamplinglCharacterizatfon <br /> L Public Water System <br /> If di forest from Owner. a er yr em N=e Contart Nams Or Flhano Number <br /> TYPE OF WORK D New Well J Replacement Well 0 Well Alteration/Modification 3 Other <br /> C Monitoring Well(s) #of wells D Soil Bodng(s) sof borings AGeotechnical -1 or borings <br /> f Out-Of-Service Well rl Out-Of-Service Well Renewal „Cross-Connection Repair <br /> C New Pum O Pump Replacement G Pump Repair ,I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method r'Mud Rotary n Air Rotary 4 Auger n Cable Tool I Push Point n Other <br /> N <br /> Proposed Well Depth ft Excavation (O in diameter o Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/GaugelASTM Schad _Steel D Plastic C Stainless Steel C Other <br /> Grout Seal Depth ft 1 Neat Cement(94 tb bagS40 gal water) U Sand Cement sack mfrl7 gal water <br /> - Bentonite(2011.solids) k Other6011— /lbs /�G 6:W• (F G17. U3 ✓</TO �j <br /> Grout Placement Method I.:Pumped :1 Free Fall =Other LI Retardant I Accelerator(name) ` <br /> PEDESTAL Installed By Ll Driller t7 Pump Contractor - Other <br /> LJ Concrete Pedesta)Dimensions:Width R Length ft Thick in L Christy Box is Stove Pipe <br /> PUMP rl Submersible;-i Turbine -:Other HP Pump Set ft Standing Water Level R <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 'I <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. �} <br /> MINIM OUR ADVANCE NOTICE <br /> cREQUIRED <br /> �FOR INSPECTIONS /�+ <br /> SIGNED TITLE 7CJ"wfN�4� DATE 7/J �?+ <br /> NEW <br /> + -. - <br /> PAYMENT <br /> RECEIVED <br /> AR 0 5 2012 <br /> H JOAqu N. <br /> FWRONi,re h'Y <br /> :Sir�L J i;:4t 1.TNp� rwENT <br /> EPARTMENT USE ONLY 7 <br /> Application Accepted By Date Area Employee ID# r <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection _ Date WAIVER Received <br /> Soil Boring Ins llo Dale Constructed Well Depth ft <br /> COMMENTS . Y C <br /> / �fylat�lE�ZA9�EJt �s�-ly7:s,Fx�t� <br /> PE SC Received ChackNI- Amount Permltt <br /> Codes We, By Cast Remitted Date Service Request# Invoice# Well ID# <br /> t437 (S?) 3t(9g"� 3g9.c .3 5 z 5,2�fo�IS4 <br /> EHO-iCo WELL RUMP PERMIT <br /> a04,08 <br />