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/OAth <br /> WELL/PUMP PERMIT <br /> SAN JOAOUM COONTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HA LTON AVENUE-STOCKTON CA 96206- (209)4693420 <br /> NDN-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDDRR,ESSSSSI �J /�U-J, CRY/ZIP wL�l� IS 2-q,-L, <br /> S� <br /> CROSSJTREEr R /f+LJ APN nSS_IrPO -�3 PARCELSgE�wS MLA.DI/SE APPLICATION# q <br /> ' -7G6 <br /> OWNER NAME � �} u PHONE <br /> fie <br /> OWNER ADDRESS /�///lJ�/ol �aJL/O �O CIWISTATFRIPAA " 2 -; <br /> CONTRACTOR /yfOp/IA�!/vt1S <br /> ' PHONE 93�3z�t7 <br /> CONTRACTOR ADDRESS LIZO /�-M-� C"ISTATEIZIP Vk <br /> SUBCONTRACTOR PNONE <br /> SUBCONTRACTOR ADDRESS CITY(STATEIZIP <br /> LICENSE '1 C-57 'I C-61 11 D-09 ❑ Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: COOT0114tes X Y TOWrlehlp Range_ SOCNOn_ <br /> IMTENOEO US I_i DOTRESUCJPTIIvate ❑ Irrigation/AgrlCuhural Yrdosit,181 u Water Quality Monitoring ❑ Soil Sampling/Characterication <br /> _I Public Water System <br /> If tlllrHml fi m0. acre ref a U H <br /> TYPE OF WORK (New Well LI Replacement Well a Well ARerationlModiRCation ❑ Other <br /> rc Monitoring We"(S) #of wells a Soil Bmiag(s) as n9° ❑ Geotechnical aa1bon"9' <br /> Jl�'Ou40f-Service Well ❑ OutAf-Sarvica Well Renewal ❑ Cross-Connection Repair <br /> ew Pump <br /> TI Pump Replacement II Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method [; MW Rotary O Air Rotary 'J Auger I Cable Tool ❑ Push Point ❑ Other <br /> N <br /> PLOIKped Well Depth xao R Excavation� in diameter ii Open Bottom 'hl;graval Peck/Graval 5¢e in diameter <br /> I Conductor Casing in diameter I Conductor Casing Depth_9 <br /> Well Casing Oiameter/oIn 7rlckness/Galge/ASTM Schell :!,, JtI Steel (Plastic ❑ SieinllTss Steel u Other <br /> Grout Seal Depth —1Q,ft I, Neal Cement(941b beg76-10 gal water) ❑ Sand Cement sack mlxO gal water <br /> jilBemende(20%solids) I Other <br /> Grout Placement Method umped rl Free Fall nOther _ ❑ Retardant/Accelerator(name) <br /> PEPSI Inalmlkd By I I DrigeT ump Contracmr I I Other <br /> I Concrete Pedestal Dimensions Width R Length ftThick in F, Christy BOX a Stove PIPs <br /> Pun-' ASubmemlble'I Torbine Other HP Z.5 Pump Set _ 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 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CO PENSATION LAWS. <br /> ORI ANCEENNOTICE REQUIRED FOR IIVYECTIO S - PLEASE CALL(209) 953-7697) <br /> SIGNED TI f� DATE <br /> 1 - <br /> 2TZ— N <br /> 7 70 - Clfv DEPARTMENT USE ONLY ll�� <br /> Application Accepted By - �r� Data 13 Area BD�' -I� Employee lD# WVIEI ups`^ <br /> �L�GmuulllInspechon Date ❑ SPECIAL Well Permit <br /> «7��p-�Y'//PP�aJF��ip fns Date ❑ WAIVER Received <br /> Pv#Yd#ng Inspection Date Constructed Well Depth R <br /> COMMENTS <br /> PESC Received hac Amolmt Date Permlif invoice# Weil Im <br /> CI <br /> WAS InlO S Remittetl Send.Re oast# <br /> 340 /° ( 0 <br /> % t <br /> fNO IaVs p-Tq/r rA6T/-c ILr C 7 leLOE6-f"`�"'T LL RUMP PERMIT <br /> error <br />