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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> v. <br /> �ULlLIq Ckl fry RdycktzYl �'152K " <br /> Jae ADDRESS Cm/ZIP > <br /> J�/J Z C' °o <br /> CROSS STRELT�� /Y�/ A%/�-APN IXS U �JJ� PARCEL SIZE�/ LAND USE A•P�/P1L(IC�A{TIONnif <br /> OWNER NAME �j r`•��P,HONE C 0 '—�I�QI'^ LJd"I'r) <br /> OWNER ADDRESS �O,,�� )r— CITWSTATF/Zff` U:J (-- �y�cf� 'sys <br /> CONTRACTOR �L(J(�J�'I--^T�r�t��A,YI�I�CJ1lr�,�A�GQ�,,•��tlC ,fel IPkJ PHONE 2 /—'� rJ RZI CJ <br /> CONTRACTOR ADDRESS 24 o tU))c J�! FCiT "�� CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTO ADDRESS CrrY/STATE/ZIP /.��7 <br /> LICENSE C-$7 ❑C-61 ❑D-09 ❑Other NUMBER E%PIItATION DATE V i r <br /> GEOCRAPHICALf9PORMATION: Coordinates X Y Township Range Section_ -}.• <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> D'Public Water Syy99tem <br /> If dillerent f om graft. W.ta Symm ame Contact Nsme or Phom Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other fl.' <br /> ❑Monitoring Well(s)_#of wells ❑Soil Boring(s) N of boring ❑Geotechnical s or borings , <br /> Out-Of-Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair <br /> *n�=X—P­ump Replacement ❑Pump Repair (\ <br /> WELL CONSTRUCTI N �) <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger 13 Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other C <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water G <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted l <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) O <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> 1 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. 1 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 /> HOUR ADVANCE NOTIC REQUI ED FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> O l`t <br /> D A TMENT US ONL.'Y --1 q 1 <br /> Application Accepted By / ate Z Q Area Employee ID# [ 1 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date /O/,Z C/o6 ❑ WAIVERReceived <br /> Constructed Well Depth ft <br /> COMMENTS 6�lrsraa�._ arcr2�iaar*�C2�' <CrY p tr fu-/? ek (s D r r <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service R uest# <br /> Lly/-05_0 <br /> ERD 63-02006 WELL PUMP PERMIT <br /> 127(100$ <br />