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J TOW Qar tvi/l(o ) y3V y3e� <br /> 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 1 YEAR FROM DATE ISSUED <br /> `/ <br /> JOB ADDRESS CITY21P //77�T_(�Q UeA/ <br /> CROSS STREET UOA S APN f— (-ZW f 2 PARCEL SIZE r 1.1 LAND 1USE/ Ll APPLICATION-#7 c <br /> OWNER NAME 7A L <br /> b �rcw4o fN � go) f&O PHONE "I 3- <br /> OWNERADDRESS X59.9 'l . Cz W1*An- a CITY/STATETP 0a Lido It i CA /�, q/5�36 <br /> CONTRACTOR Mase-11 t C TJV'I1];" Z%C' PHONE /5 Z�" I eI 'A -7 <br /> CONTRACTOR ADDRESS L l_L A I X�4 CITY/STATE/ZIP A t6 r S T64 ` et q!J5 I <br /> J <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATE/ZIP ..77 <br /> LICENSE C-57 fl C-61 ❑ D-09 11 Other NUMBER EXPIRATION DATED'6-/7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section_ <br /> INTENDED USE -�KDOmestic/Private ❑ irrigatlon/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterizatton <br /> ❑ Public Water System <br /> If different from Owner: afar System Name Contact Name or Phone Number <br /> TYPE OF WORK WNew Well KIReplacernent Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUgTION <br /> Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 250 ft Excavation 12- in diameter ❑ Open Bottom Gravel Pack/Gravel Slzein diameter <br /> ❑ Conductor Casin In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter hick a /Gauge/ASTM Schad O(D ❑ Steel XPlastic ❑ Stainless Steel ❑ Other <br /> i <br /> Grout Seal Depth J Neat Cement(94 Ib bag/5-f0 gal water) ❑ Sand Cementsack mi X/7 gal water <br /> {'Bentonite --/ sol' U Other <br /> Grout Placement Metho Pumped ❑ Free Fall [] Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ^. Pump Contractor ❑ Other <br /> a Concrete Pedestal❑Dimensions:Width 1t Length It Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine n Other HP Pump Set ft 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 /> 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FORIINSP ECTIONS-PLEASE CALL(209)953-7697 /L <br /> SIGNED �G�!-��'-�� TITLE /✓h1 Ile/ DATE /e.) <br /> A <br /> r 17 <br /> r r <br /> I LJ <br /> At A "llik- LL <br /> p T <br /> 44- <br /> tit <br /> D PARTMENT US ONLY y ,� � <br /> Application Accepted B Date I ( Area 'l Employee IDN If 196plw1 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date El WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMME 5 <br /> C Received Check#/ mount Permit/ <br /> Codes Info B Cash Remitted Date Service Reguest# Invoice It Well ID# <br /> I S P cce00-7(a .-q10 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30112 <br />