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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 11 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 t 1TP— Cn YILP <br /> CROSS STREET I�1 1]���-t�\ t/ APN QI U PARCEL SIZE I i. LAND USE,,A,,PPPLLICATION 0 <br /> OWNER NAME � r \ + Y) PHONES <br /> OWNER ADDRESS Sc1 f-'C- CRYISTATE/LP ! 4 <br /> CONTRACTOR �I T` iy . 1� \Yl�I PHONE`StC,CI _ - 7�C�/ <br /> CONTRACTOR ADDRESS P L,X `—r uC CRY/sTATE/LP 1 1'. C A i 5 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STAT?E/Zip <br /> /C-61LICENSE `i.i C-57 C-61 _D-09 Other NUMBER ?��C1 77 EXPIRATION DATE -�� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE �>(DomesGdPrivate -.Irrigation/Agricultural _Industrial --Water Quality Monitoring Soil Sampling!Charactenzation <br /> Public Water System <br /> If different from Owner Water SyStOrn Name Contact Name or Phone Number <br /> TYPE OF WORK 71gg l XReplacement Well L Well Alteration/Modification C Other <br /> Monitoring Wells) #of wells L Soil Bonng(s) am bonrgs Geotechnical x of Dorltps <br /> Out-Of-Service Well r Out-Of-Service Well Renewal Cross-COnnection Repair <br /> 2<,New Pum -Pump Replacement C Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary - Air Rotary Auger - Cable Tool Push Point Other <br /> Proposed Well Depth �7 C> ft Excavation in diameter n Open Bottom x Gravel Pack/Gravel Size 'i 4 — in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter C,, in Thickness/Gauge/ASTM Sched 1 -r '=Steel fie_Plastic Stainless Steel - Other <br /> Grout Seal Depth C `,. R Neat Cement(94/b bag/S10 gal water) ;.Sand Cement 'r sack mixl7 gal water <br /> Bentonite(20%solids) - Other <br /> Grout Placement Method') Pumped .. Free Fag Other _:Retardant/Accelerator(name) <br /> PEDESTAL Installed By pnller Pump Contractor) Other <br /> .Concrete Pedestal Dimensions:Width ft Length t It Thick in Christy Box Stove Pipe <br /> PUMP Submersible- Turbine - Other HP Pump Seft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMU' 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 / <br /> SIGNED �C C- r t/tJ.��t/� TITLE \i C ' t �'C r c1 C rl DATE <br /> ct <br /> Q <br /> � I <br /> 17t 11 1 1 <br /> TY <br /> LN A <br /> H E I DAJ IT FL NT <br /> Y <br /> 4PAIIRTMENT U E ONLY <br /> Application Accepted By a -Date Employee ID# ��/O <br /> _ SPECIAL Well PermitGrout Inspedi Date <br /> Pump Inspection By Date _: WAIVER Received <br /> Soil Boring Inspection By Date ( Cons cted Well Depth ft <br /> COMMENTS��SVA L, ��(,�tGJ <br /> PE SC I Received Check#1 Amount Perm'U <br /> Codes Info B Cash Remitted DataService Re uest# Invoice# WeIIID# <br /> sro 1AK ° ► 1 <br /> t S -19 <br /> EMD J7�^8 WELL!PUMP PERMIT <br /> V30". <br />