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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAW STREET - STOCKTON CA 95202 - (209) 4683420 <br />Nrn\I_0-1-nA21 c PCRMrr CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />- Z- R m1Zw T� <br />325 � S , IICoS �c.•r as Ot C <br />SC <br />info <br />305 ADDRESS <br />739.3 3 <br />SSS' t OU -Zb PARCEL SIZE LAND USE APPLICATION # <br />a <br />CROSS STREET • 3 APN <br />Date <br />pW <br />[[� � VG(� PHONI� o 15 Z 0-8 %k Q <br />' <br />OWNER NAME E'i h � \ 0. � ...�0. v� S Q <br />V <br />L / CrrY/STATFJZIP <br />52-k&KoSix^I 9-04d <br />r <br />U <br />OWNERADDRESS 12 <br />r <br />PHONE <br />CONTRACTOR <br />Crrr/STATEIZIP <br />4 <br />CONTRACTOR ADDRESS <br />It <br />PHONE <br />SUBCONTRACTOR <br />V <br />CrTY/STATEIZIP <br />SUBCONTRACTOR ADDRESS <br />LICENSE D C-57 C C-61 C D-09 C Other. NUMBER EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />$ <br />INTENDED USE A DomesticlPrivate C ItTigaUonlAgricultura! J Industrial C Water Quality Monitoring C Soil Sampling/Characterization <br />_.. Public Water System o ame or um r <br />If dlffatem from Owner: r em arse <br />- TYPE Wort ❑ New Well L Replacement Well ❑ Well Alteration/Modification C Other Aofbctinp <br />0 Monitoring Well(S) # of wells G Soil Borings) n of borings I-, Geotechnical <br />n Out-0fSer,iCe Well D Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />X New Pum I Pump Replacement D Pum Re air D Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method _ Mud Rotary D Air Rotary C Auger .7 Cable Tool U Push Point D Other <br />Proposed Well Depth ft Excavation in diameter D Open Bottom C Gravel PaWGravel Size in diameter <br />D Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter Thickness/Gauge/ASTM Sched G Steel C Plastic ❑ Stainless Steel C Other <br />_in <br />Grout Seal Depth ft D Neat Cement (941b bag15.10 gal water) C Sand Cement sack miX/7 gal water <br />u Bentonite(20%solids) D Other <br />Grout Placement Method -1 Pumped Ci Free Fall G Other i_ Retardant / Accelerator (name) <br />PEDESTAL Installed By 'i Driller G Pump Contractor n Other <br />In Ci Christy Box Stove Pipe <br />L Concrete Pedestal Dimensions: Width ft Length ft Thld <br />PUMP R Submersit1leC Turbine a Other HP __3-_ Pump Set 17- O ft Standing Water Level UP ft <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THI5 APYLIGAIIUN AnLJ InAI Inc ...,,.,.--- -- --•-- •------•------- <br />JOAQUIN 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 />{14INNIIM,U�M24HOUR <br />� ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />c-- �..FJ. 2 �'1+.tfIW..JC�7`"'` TME n :)'—Q+rDATE t 0 <br />■■■■■■■■■■■■■■■■■■■ MEM <br />■■■■■■ <br />■■■■■■■■■■■■■■■■■■■ MEN <br />■■�■■v <br />■■■■■■■■MEN ■■■■■■■■■■■■■■■■■ <br />■■■■■■�N■■■A■■■N■■��■■■ <br />Area _ Employee ID# <br />SPECIAL Well Permit ((( <br />C WAIVER Received <br />Constructed Well Depth ft <br />1 <br />PE <br />Codes <br />SC <br />info <br />Received <br />B <br />Check#/ <br />a <br />Amount <br />Remitted <br />Date <br />PermInvoi-# Well ID# <br />Service Re quest# <br />osv <br />Ze-- <br />2 4 <br />sc�. eo <br />r <br />0 5` z 1 iu vd 3 3 <br />