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WW29 . <br />`^ lc� � It <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 />JOB ADDRESS <br />CITY/ZIP �, A Vi A L , 7u V/ <br />CROSS STREET NPN <br />PARCEL SIZE e LAND USE APPLICATION # <br />hh <br />I'mrl <br />OWNER NAME <br />PHONE <br />Z O O Z(JmvduA <br />OWNER ADDRESS -0 <br />CITY/STATE/ZIP <br />CONTRACTOR , 1 t hb. <br />PHONE <br />CONTRACTOR ADDRESS PD B D)� 1 ✓� <br />CITYISTATE/ZIP- <br />SUBCONTRACTOR \ <br />r,�0 E <br />SUBCONTRACTOR 1)DRESS <br />STA Z <br />LICENSE �/G-b7 C-61 D-09 Other�,, i b <br />NUMBER E%PIRATION DATE <br />• <br />GEOGRAPHICAL INFORMATION: COordlne s Y <br />•I'l Township_ Range Section_ <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial <br />Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water yStern Name <br />Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) <br /># of borings Geotechnical # of borings <br />Out -Of -Service Wellgut-Of-Service Well Renewal Cross -Connection Repair <br />New Pumo PumD Reolacement ✓PumD Repair <br />Raise Well Casino <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 Sched 'Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 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 Pedes 1 Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible./Turbine Other HP Pump Set ft Standing Water Level ft <br />I HE ERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JO QUIN CCIXNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />Q(IRRENT AIJQ ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />llllj�r 24 1 O17 ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (20933 769�j,� <br />// 6 \ TITLE DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />A <br />D <br />°a <br />N <br />RECF veo <br />rL 18 2017 <br />J0AQtjPoRON' Coll" <br />TH OE 41 E MFA» <br />EPA TMENT UPE 014LLYJ <br />Date ' J� / / x„ / Area Employee ID# br/ 7 <br />Date J --r �--F -1 SWell Permit <br />Date cl I ( 1 WAIVER Received <br />Date Constructed Well Depth ft <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />