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iz, r <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />-r��rurvu,vo�t rtr<mt I trALL J,4UJI 953f�-7769�117 FOR INSPECTIONS EgX`PtIR, Ef\lS I YEAR FROM DATE ISSUED <br />Joe ADDRESS �!�\0\ V `Jt�, � .\77���i/�. CrTYrzIIP ` OCX? TC,/r j C. -!T <br />CROSS STREET \.� \L-L�l APN DV) I �T''t C <br />l7 PARCEL SIZE ZLAND USE APPLICATION n <br />OWNER NAME --r vSZ, J\ R_(_0 Ta-- Cc,r 0-J Wo <br />`� <br />OWNER ADDRESS I,`Gt`�� Imo, ��� t"�y'r�V- �Y��W\' CITYISTATE}ZIP j�A•OwS3C�rF�j� ►C: N-I� <br />CONTRACTOR V Ct v. (� C_P `C . �r ` i /Z �� `!1 r `_.O7 5i— PHONE r+ i '�.. - -�) 'Y , <br />CONTRACTOR ADDRESS, S 3 0 � ( f ��_r�.�n c'� r. �' S`' `"T• CITYISTATE/ZIP I /�) C f+ ! r.'�. •`.-.: 1 P ! I •.I CI <br />V l <br />SUBCONTRACTOR )/ ( I 1 .-t !- PHONE 7 Crt _r +'� 'C •J <br />SUBCONTRACTOR ADORESS .i-_ V ( �` ! ' : r--.^.( CIT'}Y)STATE/ZIP <br />LICENSE '-C-57 C-61 .: D-09 Other NUMBER Leri f 't E%PIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X )-d- t7 k Y — U-1 . I, l0\,'A TOWnShin Rana. Sar•finn <br />INTENDED USE DomesticiPrivate Imgation/Agr:culturat Industrial Water Quality Nlonitonng oil Sampling/Charactanzation <br />Public Water System <br />If dieerem I— Owner a ar aysiam, ame on 1.n. ame or ono emcer <br />cn 11— me p- -mem Wen Well Alteralion/tilodlilcation Other <br />Monitoring Well(s) 9ofwells SOiIBonn s xorbonngs xof(rings`` <br />91 )116.technical <br />Out -Of -Service Well' Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary AT Rotary vAuger Cable Tool Push Point - Other <br />Proposed Well Depth_Z_ (3 ft Excavation U in diameter Open Bottom Gravel PacklGravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness!G�aauge/ASTNI Sched Steel Plastic . Stainless Steel . Other <br />Grout Seal Depth ft \e al Cement (94 !b bag/5-10 gat water) Sand Cement sack m&7 gal water <br />- Bentonite (2 . solids) Other <br />Grout Placement Method ped - Free Fall Other - Retardant / Accelerator (name) <br />PEDESTAL Installed By . Driller Pump Contractor - Other <br />Concrete Pedestal Dimensions: Width _fl Length ft Thick In Christy Box . Stove Pipe <br />PUMP Submersible - Turbine - Other HP Pump Sal it Standing Water Level R <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 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 />MIN U HOUR ADVANCE NOTICE REQUIRED FO INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED I C X C�, U_� C i R-1 TITLE r C (- L �: +l r, , n L'L l DATE " I 1-2) ) I U <br />!o <br />D <br />a <br />A <br />m <br />N <br />�.�/t�.��/ :P RTMENT S E NLY( <br />{/,�► <br />Application Accepted B+e >� 1 Date ���1(o Area OL ` Employee ID9_ <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection _ r Date = WAIVER Received <br />SOII Boring Ins coon By -C C`,Date [ �% Lf Constructed Well Depth R <br />COMMENTS ifG �7f /P J Lb�i' iCC "�6i1 <br />Vic'%iii C_.c r / �•t,t�<, � `- <br />PE <br />Codes <br />SC <br />Into <br />Received <br />B <br />Check <br />- <br />Amount Date <br />Remitted <br />Permit/ Invoice R <br />Service Request p <br />Well iDi1 <br />1120 1: Il='_L ,c�.M1IP Pgbll' <br />