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V114 F <br />5 <br />I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAMILTON AVENUE -STOCKTON CA 95205 - (209) 468.3420 <br />NON-REFUNDABLE PERMIT <br />1PJMIMIIT/V\— <br />JOB ADDRESS - - <br />CROSS STREET <br />OWNER NAME V, <br />CONTRACTOR W ✓WY' k. V / <br />CONTRACTOR ADDRESS1909 <br />L I T)a ` <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS q Y <br />LICENSE C-57 C-61 D-09-09 <br />GALL ZUl 153 -/till FOR INSPECTI t1lF'IKtJ T TEAK FRUM UAIE IS,UtU <br />u u 1n Yr G q5 <br />CITY(ZIP <br />_ APN 1 0a OLk PARCEL SIZE I ILM LAND USE APPLICATION # <br />lin 1) ICA <br />PHONE <br />X3 7 `7 T <br />/) / Z <br />CITYISTATE/Zll CG�/� /►�Y 1�1 r. <br />VIA ill I) JAC._ _ 'F aL �� 2-0,7 U <br />_ CITYIST�ATTElZ)IP <br />NUMBER -116`, " C ` <br />GEOGRAPHICAL INFO ATION: GOordmatil 1C r —wnsmP _ rcanye �...� <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: water bystem Name ConeCt Name or Phone Number <br />IN <br />ra <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />SC <br />Monitoring Well(s) # of wells Soil Bodng(s) # of bodogs Geotechnical # of borings <br />Amount4Date <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />CY <br />New Pum ump Replacement Pump Repair Raise Well Casing <br />Info <br />WELL CONSTRUCTION <br />Remitted <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Service Request # <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 Ib bagl5-10 gal water) Sand Cement sack mix/7 gal water <br />D� <br />Bentonite (20% solids) Other <br />(, <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />oncrete Pedestal Dimensions. Width ft Length ft Thic in Christy Box Stove Pipe <br />PUMP V Submersible Turbine 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 FORASPECTIIO/NySy- PLEASE CALL (209) 951-7697 <br />SIGNED TITLE w r / I C4!_ DATE tO N <br />i Q <br />EPARTM ENT USE ONLY <br />f L, <br />Application Accepted By / Date 10. x 3 - Area L G/ Employee ID# hM <br />Grout Inspection By Date _ SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />SC <br />Received Check#J <br />Amount4Date <br />Permit/ Invoice # Well ID# <br />)des <br />Info <br />B <br />Remitted <br />Service Request # <br />D� <br />U <br />Y��% <br />p CFOV�O <br />Cr?3 ?01� <br />V► /"R V/y � <br />Ty pM� MAS <br />T <br />