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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3'm FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEARM� FRODAATE ISSUED <br /> 40/ <br /> JOBADDRESS i - - ._-- - CITY/ZlP //� <br /> _(�{ ea:aj p—O �R' /g-Pz rn <br /> �y� —/ 'FJ O <br /> CROSS STREET APN(/vS 7.60-T/ PARCEL SITEW�RLAND USEAPPLICATION N ,`^s <br /> OWNER NAME I.(/ LPHONEn'- <br /> OWNER ADDRESS a C C ,CITY/STATFJZIP_�w�y7.1 <br /> CONTRACTOR "PHONE <br /> CONTRACTOR ADDRESS CrrY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR All SS CrrY/STATE/ZIP <br /> LICENSE 57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE 7—'La <br /> GEOORAPHICALINFORMATION: :Coordinates yY Township_ Range Section_ <br /> INTENDED USE ❑Domestic/Private MIFTigationtAgricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ifdiff[from Owner. W.,er ystem Name Coftne amen Phone Numixt <br /> TYPEOF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) N of wells ❑Soil Boring(s) o of bo"g' ❑Geotechnical I of hodngr <br /> ❑Out-Of--Service Well ❑Ottl- -Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum Cl Pum Replacement �R air n <br /> WELL CONSTRUCTION - <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Ex� in diameter„ ❑Open Bottom rave Pack I Grave in diameter <br /> ❑Conductor Casing in diameter uctorCasing It <br /> Well Casing Diameter_in Thickness/GaugeASTM Sched Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Groot Seal Depth ___ft ❑Neat C bag/S-10gal water) nt sack mix 17 gal water <br /> ❑Bentonite(20%solids) nufacturer Spec%solids % Name Specs on File ❑Spxs Submitted <br /> Grout Placement Metho ped ❑Ftee Fall ❑Other El Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft -Length ft Thick in ❑Christy Boz ❑Stove Pipe <br /> PuMP ❑Submersible urbine ❑Other HP� Pump Set ft Standing Water Level it <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 LAW'S,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE 1S <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAW'S. <br /> f <br /> MINIM 1 4 HO IR ADVANCE NOTICE UIRED FOR INSPECTIONS ��jj't1 //�► <br /> SIGNED t TITLE DATE <br /> 1 <br /> Fr- <br /> I 4a <br /> INI <br /> QV <br /> :DE AR MENT USEO LY <br /> Thr vApplication Accepted B pate � Z QV Arca Employee IDSL� "tl <br /> Grout Inspect' n By Date El SPECIAL Well Permit f <br /> Pump Inspection By Date� WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Receivedcil.—OV Amount Date Permit/ (nvolcetY WeIIIDk <br /> Cod Into B Cash Remitted Service Request H <br /> DID 43.02A06 WELL PUMP PERMIT <br /> 112713005 ' <br />