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r <br />WELL/PUMP PERMIT <br />! 1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDA51LE YEKMI I <br />L.ALL tZIOV) 7103 -/ OJ/ FUK IN51'tU I IUN5 <br />CAYIKGJ "1 T tAK PKUM UAI t ISSUtU <br />- <br />A <br />C. L�11'� R, <br />C� C� —�L.' <br />JOB ADDRESS—1, <br />pc, CITYZP �-L' <br />r� (`.� <br />CROSS STREET l j -,e Y11) C <br />-i C K <br />I DAPNOI7- 77-0-03 PARCEL SIZE LAND USE APPLICATION X <br />:)C C1 ���7: � <br />OWNER NAME �� ll y- r ! <br />Pell I <br />PHONE `-j <br />OWNER ADDRESS 1 l /1 � C <br />1 ^�� <br />V i \ I <br />�: i, I� f CITY/STATFILP <br />r /�� <br />,w� "1 c% <br />(; !"� l �. �� "t—r <br />CONTRACTOR /'nt <br />1-7) C' <br />I I ,,�IY 'i <br />�J1 <br />PHONE 3C: Li -7 /-1 <br />CONTRACTOR ADDRESS _` � <br />13 n 'A <br />� t . -r CITY/STATE/LP <br />/-� 1 <br />C r 5 � 4- I l -'=\ (I S 6, <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STAT/E�/LP <br />LICENSE � X13 C-57 C-61 <br />D-09 <br />_ Other NUMBER 21I -� <br />` <br />EXPIRATION DATE 'a-7— S I ` � i <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE XDomesticrPrivate - Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner, Water System Nam Contact Name or Phone Numbw <br />TYPE OF WORK ';4 New Well - Replacement Well - Well AlterationNodification _. Other <br />Monitoring Well(s) # of wells Soil Boring(s) a of Wrhg' Geotechnical x of bonnas <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />WELL CONSTRUCTION <br />Drilling MethodAMud Rotary Air Rotary Auger Cable Tod - Push Point Other <br />Proposed Well Depth `{ft Excavation i in diameter r". Open Bottom Gravel Pack/Gravel Size )14 In diameter <br />Conduct Casing in diameter ! Conductor Casing Depth tt <br />Well Casing Diameter in Thickness/Gauge/ASTMSchad (.I LZ; e) L Steel APIaslic 7 Stainless Steel _. Other <br />Grout Seal Depth �y; j]_ft Neat Cement (941b bag/5-10 gal water) Sand Cementer (: 71 sack mixR gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped _� Free Fall Other L Retardant / Accelerator (name) <br />PEDESTAL Installed By )CDrilier Pump Contractor:Other <br />Concrete Pedestal -Dimensions: Width It Length It Thick in Christy Box Stove Pipe <br />u P "?(Submersible- Turbine Other HP_7_ Pump Set h 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 FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />�s�-SIGNED (L�'w_TCb�- TITLE \� C I Cl i VI T DATE ICI r <br />MElT <br />�pYRECEDED <br />OC.� �'1 2016 <br />COUNT`b <br />IA EN HQ PAATMEt'� <br />H�pLTH <br />AR MENT SE ONLY <br />�J <br />Application Accepted ate r)Area Employee <br />Grout Inspection ate l Al PECIAL Weil Permit <br />Pump Inspection *By 'N Date _] WAIVER Received <br />qv <br />