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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAW STREET-STOCKTON CA 95202-(208)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTIONS I., EXPIRES 1 YEAR FROM DATE iSSU£D <br /> r/�/��. <br /> Joe ADDREss 1 CITY/ZIPI &.a,-0.�1,— — <br /> OA4 <br /> pp- / o <br /> CROSS STREET API !6S- dfRXJ-'� PARCEL SIZE'T-Qs LAND USE APPLICATION# •�O m <br /> OWNER NAME PHrON � 4 1 <br /> OWNER ADDRESS Cr1Y/STATEIZIP "I <br /> CONTRACTOR PHON I <br /> CONTRACTOR ADDRESS_ CITYISTATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRAADDRESS C •TAT IP :l <br /> LICENSE C-57 0 C-61 0 D-09 0 Other NUMBE EXPIRATK)N DATE <br /> GEOGRAPHICAL INATION: Coordinates X Y Township! Range Section <br /> INTENDED USE omestic/Privale 0 Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> R OIRererR hom Owner. Water system Name GO1.N."Or PhOM NUMIr I! <br /> TYPE OF WORK 0 New Well 0 Replacement Well ❑Well ARerationlModification ❑Other <br /> # <br /> ❑Monitoring Well(s) #of wells 0 Soil Boringof borings s) 0 Geotechnical #of borings <br /> 0 Out-Of-Servlce II D Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pum Pum Replacement 0 Pump Repair 0 Raise Well Casing !I <br /> WELL CONSTRUCTION `I N <br /> Drilling Method ❑Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool G Push Point 0 Other i p <br /> Proposed Well Depth It Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in'diameter 'Ss <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft ii N <br /> Well Casing Diameter,_„_in Thickness/Gauge/ASTM Sched 0 Steel D Plastic 0 Stainless Steel 0 Other 1 <br /> Grout Seal Depth It 0 Neat Cement(94 lb bag/5.10 gal water) 0 Sand Cement Sack mur/Tlgal water M <br /> 0 Bentonite(20%solids) 0 Other_ I,I <br /> Grout Placement Method 0 Pumped 0 Free Fall ❑Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑Pump Contractor ❑ Other q <br /> ❑Concrete Pedestal Dimensions:Width It Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine 0 Other HP Pump Set ft Standing Water Level i <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WPfH SAN q <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS Ci <br /> CURRENT AND ACTWE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL b <br /> WORKERS COMPENSATION LAWS. <br /> M 24 HO R ADVANCE NOTIC EQUIRE FOR INSPECTIONS �I <br /> SIGNE TITLE DATE I <br /> I <br /> l <br /> I <br /> it <br /> i <br /> R N EN' <br /> i <br /> DEPARTMENT^USE ONLY <br /> Application Accepted By Date Area Employee ID# •I[4 1 <br /> Grout Inspection By Date ❑ SPECIAL Weil Permit I` <br /> Pump Inspection _ � Date Z/ 0 WAIVER Received <br /> Soil Boring inspection B Date Constructed Well oeoth If ft <br /> COMMENTS a/17 <br /> PESC Received Chec Amount Perm <br /> Codes Info B ash Remitted Date Service Re ,est# Invoice# Well ID# <br /> v <br /> �S$7 0sa I So.aV1-7I ,-7400577 .3Zz <br /> I <br /> ENO xUMP PE <br /> 8 ELL>PRWT <br /> f <br />