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0 <br />WELL/PUMP PERMIT <br />SAN JOADUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL(L209 953-7697 FOR INSPECTIONS EXPIRES t YEAR FROM DATE ISSUED <br />(1,� <br />JOB ADDRESS ✓' i '' CITYIZIP �� m <br />D <br />y� r� /� 0 <br />CROSS STREET ` /V' ` - APN� �O PA EL SIZE JLAND USFj4PPLICATION # A <br />OWNER NAME <br />C <br />PHD^E v <br />OWNER ADDRES <br />r <br />CONTRACTOR <br />//, 0 <br />Vl V <br />/) /� �/�/) <br />V l.� 7 ( <br />CITY/STAT ZIP GGG U/ <br />PHONE <br />CONTRACTOR ADDRESSq0 <br />�/1 / /�/ //� ,1 <br />L `�" I V V/ <br />N <br />1 - <br />ITY STA <br />SUBCONTRACTOR <br />PHON <br />SUBCONTRACTOR ADDRES <br />CITY/STATE'ZIP <br />2 <br />LICENSE C-57 <br />C-61 D-09 <br />Othef 1 <br />NUMBER `� b EXPIRATION DATE <br />iEOGRAPHICAL INFNATION: Coordinates X Y Township _ Range Section_ <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: ater bystem Name UortaCI Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Borings) tt of borings Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Vyell Renewal Cross -Connection Repair <br />New Pumo Pump Reolacement Pump Re-- - Raise Well Casing <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 diamet <br />Conductor Casing in diameter I Conauctor Casing Depth It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib 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 />ncrete Pedestal Dimensions: Width ft Len th ft Thick in Christy Box Sto e F)pe <br />PUMP 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 ITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPE N LAWS. <br />MINIMY O ADVANCE NOTICE REQUIRED FO?NSPECTI/ONS -PLEASE CALL (20�) 3-76 <br />SIGNED / TITLE l_ DATE <br />2 ? 2017 <br />HEALTH <br />P <br />,N RFcFMFo� <br />R h �M <br />114 7;t, O 04, Cc) <br />°F �HVA� <br />EPYIRTMENT SY <br />Application Accepted By Date Area Employee ID#704:j`J Y / Ci(V <br />Grout Inspection By Date PECI Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth It <br />COMMENTS <br />PE SC Received heck#! Amount Date Permit/ Invoice # Well ID# <br />Codes Info B Remitted Service Request # <br />�a �� I L1 1 W POO3W3S <br />