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c , <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 <br />2209 953-7697 FOR INSPECTIONS <br />1 YEAR FROM DATE ISSUED <br />JOB ADDRESS O Q <br />�[CI}AL'(L <br />1 /VrJ `�r1 Cha <br />T�EXPIRES <br />530,4 <br />CITY/ZIP \ V <br />�^c�! \ <br />��'' 1� <br />CROSS STREETAJ <br />2 <br />APN k <br />' PARCEL SIZEL 1- .3,- —LAND <br />USE APPLICATION # <br />,y <br />OWNER NAME \ �/j�1.L <br />n <br />('V>V� <br />n <br />I <br />OWNER ADDRESS <br />A. q -q <br />KI <br />TrPHONE <br />CITY/STATE/ZIP ` • ""�� <br />�/� O,^�1'• <br />T?D <br />CONTRACTOR ,= J ``/�'�,ai'lew <br />1o) 11( ]� �! <br />1S <br />o{n-,- AL1 �l�` <br />� /'� <br />PrH7O E4O <br />CONTRACTOR ADDRESS Jaq <br />-TU t,� �/� <br />j,�/�1 <br />CITY/STATE/ZIP y' <br />lI <br />CA Q00, CAr_ Q <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITYISTATE/ZIP <br />LICENSE C-57 JC -61 <br />D-09 i Other <br />NUMBEtX <br />j <br />EXPIRATION DATE \ I -A6 <br />GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range Section_ <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water 5YStern Name ConteCt Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Bodng(s) ft of borings Geotechnical Y of borings <br />Out -Of -Service IMM. I ut-Of-Service Well Renewal Cross -Connection Repair <br />New Pura 'um Replacement um Re air Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ' Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP]!CF, Pump Set i ft Standing Water Level It <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 />W <br />9 <br />DEPARTMENT USE ONLY <br />Application Accepted By Aj"Date � Area 0 � R Employee ID# <br />Grout Inspecticn By Dat 1 I ^� V <br />CIAL Well Permit <br />Pump Inspection By D f ,(._'� IVER Received <br />Soil Boring Inspection By Date Constructed Well Depth It <br />COMMENTS <br />_ __ < _..__.... ._..__..- Data """" Invoice# Well <br />Codes Info B ash Remitted Servi":. equest# <br />3 s x-2053 s�"`' t o73l0 7 Wpo <br />EHD 43-06 <br />4130112 WELL /PUMP <br />