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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-f209)466-3420 <br /> NON-REFUNDAB / atl.2— r LLd2Y-g 3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1. ''''{{ ASSOG•'M e�1 "�` 5��. - Q.w�c+l CITY/7j L.oc..�C.Q <br /> D <br /> Cn.,,r-� <br /> CROSS STREET 31d'""aS tld� ►/� I '/ APN OSI^31 O-SZ- PARCEL SIZE <br /> /�c•8C,9 LAND USE APPLgICATION# <br /> OWNER NAME Sohv. * KAC�., Y,.&j C� (ir�1D PHONE_-Z� <br /> m <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTORSgtt`JJL�lr�t"'� ^tt C- r PHONE_ Z.� ��V V ►1,�5+ <br /> CONTRACTOR ADDRESS <br /> tt-1 9 V4,�,)p.cq{At 11h Ply ♦ CITYISTlATTEIZJP IPY-4--4'J (,\A <br /> SUBCONTRACTOR �N � �(��L PHONE <br /> SUBCONTRACTOR ADDRESS C1TYtSTATTE)71P 1 <br /> LICENSE 71 C-57 - C-61 D-09 "1 Other NUMBER '0%-jor-Vsl- EXPIRATION DATE 3 131 <br /> GEOGRAPHICAL INFORMATION: Coordinates X 2 e• I S�J! �{ <br /> Y all,. I52,-f Township_ Range Section_ 1 <br /> INTENDED USE Domestic/Private I Irrigation/Agricultural .,Industrial ';Water Quality Monitoring )(Soil Sampling/Characterization <br /> Public Water System__ w <br /> If dltterent from Owner - - a er ys em am—IT e- o a� ame or ane u r y„ <br /> TYPE OF WORK ❑New Well Replacement Well I. Well AReration/Modification :Other N <br /> r'Monitoring WeII(s)____#of wells Soil Boring(s)s —*,f bon as Q <br /> X g( ] c] g' j X Geotechnical� �°r bon <br /> n Out-Of-Service Well C Out-Of-Service Well Renewal :Cross-Connection Repair <br /> New Pump :Pump Replacement C Pump Repair Raise Well Casing _ <br /> (WELL CONSTRUCTION <br /> Drilling Method ,Mud Rotary Air Rotary X Auger Cable Tool Push Point i Other (� <br /> pd <br /> Proposed Well Depth 10 50' ft Excavation es in diameter Open Bottom .Gravel Pack/Gravel Size_ in diameter <br /> iConductor Casing _in diameter / Conductor Casing Depth _ ft <br /> Well Casing Diameter _in Thickness/GaugelASTM Sched 'Steel Plastic Stainless Steel Other <br /> Grout Seal Depth_Q ft XNeat Cement(94 lb bag/5-10 gal water) Sand Cement _ sack mixr7 gal water <br /> C Bentonite(20%solids) ;:Other <br /> Grout Placement Method I'_r Pumped -I Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller n Pump Contractor J Other <br /> R Concrete Pedestal FIDimensions:Width It Length ft Thick in Christy Box Stove Pipe <br /> PUMP C".Submersible'..'Turbine Other HP Pump Set it Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 /> ( <br /> MIM UM 24 jkJRt�11D A CE NOTICE REQUIRED FOR(INSPECTIONS-PLEASE CALL(209)953-76917 <br /> SIGNED (• C�- TITLE 3 I^ ��C�� � DATE (9 t-Z-J- l 1 Ll <br /> Z Z <br /> =JW <br /> 42 C Z Ul o O <br /> N L)Z(= <br /> LW <br /> W zga <br /> 0 UJ <br /> Q W a>x <br /> 0. -"jZ� <br /> aWLU <br /> cn = <br /> ARTMENT USE NLY <br /> Application Accepted By Date 2-7 1 Area Employee ID# G51;'o�"t7 <br /> Grout Inspection By Date L SPECIAL Well Permit <br /> Pump Inspection Ci WAIVER Received <br /> Soil Boring Inspection ate Constructed Well Depth ft <br /> COMMENTS L O - S <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well Il?# <br /> Codes Info IS Cash Remitted Service Re uest# <br /> I�0 <br /> EHO 43-'W WELL/PUMP PERMIT <br /> 4rM1I <br />