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rA-nnaa�ss <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Goo EAST MAIN STREET-STOCKTON CA 9$202.- (209)499-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)(9953-7697 FOR INSPECTIONS EXPIRES 1 YEAR�FROM DATE ISSUED <br /> JOB ADDRESS ► ci-77�S 'Eff. 4t 61kwA^a rq`r/.� /� ) CITYpZP �04',g l� <br /> CROSS STREET- cA e4 u4 U S• APN 0/ 1 0l 0 1:q PARCEL SIZE tI L BLAND USE APPLICATION# <br /> OWNER NAME <br /> Isco =,o rC+EG N\1J(n Q. V k (4&C'71061 PHONE'11�-626-622-( <br /> OWNERADORESS (I �O ��(}�L(Ir�70D P�2K-W#r� CITYI$TATEZP S � tea\0 <br /> CONTRACTOR 1-t��i1j/�� {�A'l N� PHONE ��.�\S f `5 S Z7- <br /> CONTRACTOR ADDRESS X=44 T�zd"%e;t_J�- 'V'Artruc w" CITY/STATEZP ��FA'/�� <br /> SUBCONTRACTOR 1"C tt S��JJa``�{v Hyl NMrti� 4�'1N I� ��P�HOON1E -1`0l']�Z�y� -AO�� <br /> SUBCONTRACTOR ADDRESSa-6'TOS SIV1"r) ��� 9.0.t�R�• CITY/STATEIZIP CAtJVDt3 COUhSiir uX �t9 <br /> I&, Ae r_-10 1�,J 4 30 1y V <br /> LICENSE ❑ C-57 ❑ C•91 ❑ D-09 /Other ►'111-1. NUMBER TI-2*A / EXPIRATION DATE 1/ ` <br /> GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range_ Section_ <br /> INTENDED USE O Domestic/Pdvate ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> Ll Public Water System <br /> If Efferent from Owner: Wa te r ys emame on ac ame or Phone Nurrmr <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well 7 Well Alteration/Modification Other - <br /> ❑ Monitoring Well(s) #ofwells ❑ Soil Borings) nes ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair er <br /> ❑ New Pum ❑ Pum Replacement 11 Pump Repair ❑ Raise Well Casing1� <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point f� Other <br /> Proposed Well Depth_ft Excavation In diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing In diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/S10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other v�p <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width it Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP C Submersibloo Turbine ❑ Other HP Pump Set it Standing Water Level ft-j <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 ANDACTIVE WITH T CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATIO <br /> IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS t4 <br /> SIGNED TITLE FYUd$--° 'Fact, �"�� DATE ZD <br /> E <br /> fV <br /> IM_VA L1 <br /> I EAITH AUL <br /> DE ARTMENT USE ONLY (/ <br /> Application Accepted By �� Bate ZC Area Employee ID# CAC <br /> `C _ <br /> Grout Inspection By - Dale SPECIAL Well PerMit <br /> Pump Inspection By Date WAIVER Received <br /> Soli Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS <br /> 'PE SC Received Cheek#/ Amount - Permit/ <br /> Codes Info -"Cs9B—'J Remitted D Permit/Service Re uest# Invoice III Well <br /> 23 3`6 i% I! ZSou " th 00(047,3 / <br /> EHD 434X% wELLMUMP PERMR <br /> fiOWe <br />