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F <br />i 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 />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />�'q <br />JOB ADDRESS <br />CITY/ZIP <br />IY lien <br />CROSS STREETMk' <br />APN \)�JII� PARCEL SIZE _LAND <br />USE APPLICATION# <br />OWNER NAME <br />PHONE <br />I <br />OWNER ADDRESS 1 (�3 <br />IIIYJ! D f IV� CrTY/STATE/ZIP I lf�dl <br />,{^-�'��1Krh-�11,ba- <br />V' \+ <br />z�•J��®^7 <br />CONTRACTOR <br />I <br />PHONE��J <br />f <br />CONTRACTOR ADDRESS <br />Cm'/STATE/Z1P�I <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITYISTATEIZIP <br />z <br />�J <br />LICENSE13 <br />C-57 Iii <br />__ D-09 ,_ Other NUMSER[3�53 <br />EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates x Y Township _ Range Section_ <br />'INTENDED USE DomeslictPrivate ---Inigation/A.gricultural --Industrial Water Quality Monitoring -- Soil Sampling/Charactedzallon <br />Public Water System <br />If Nfferent from Owner Water 5riern N.W GoMmaName or ne m <br />TYPE OF WORN \/New Weq - Replacement Wel - Well Alteration/Modification Other <br />Monitoring Weq(s) sof wells :: Soil Boring(s) <br />of borings ng(s) _ Geotechnical a of borings <br />Out -Of -Service Wel Out -Of -Service Well Renewal - Cross -Connection Repair <br />)rifling Method X Mud Rotary "" Air Rotary - Auger - Cable Tool - Push Point - Other <br />'roposed Well DepthIf Excavation _ta-_ in diameter Open Botlom XGravel Pack/Gravel Size M diameter, <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _L in ThicknesVGauge/ASTM Schad.. -. Steel X Plastic - Stainless Steel Other <br />Grout Seal Deptha_tl _ Neat Cement (941b bag/5-/0 gat water) Sand Cement 10.9 sack mix/7 gel water <br />_ Bentonite (20% solids) _ Other <br />Trout Placement Method X Pumped Free Fall _ Other _ Retardant / Accelerator (name) <br />PEDESTAL Installed By ! Driller Pump Contractor Other <br />X Concrete P destal -Dimensions: Width ft Length ft Thick in - Christy Box Stove Pipe <br />PUMP - Submersible Turbine Other HP Pump Set 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. 1 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 />MINIMU 4 HOUR ADVANCE NOTICE REQUIRED FO\R/j1INSPPECTT�IyONS-/T1PLLE,�ASE CALL (209) 953-7697 <br />SIGNED �L%_�� _ TITLE FOV <br />IGC/ l 1 ��I Vl L/! I� DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Area Employee ID# <br />Grout Inspection By Date _ SPECIAL Well Permit <br />Pump Inspection By Date I WwER Received <br />Soil Boring Ins n By - Date Constructed Wall Depth ft <br />COMMENTS�Tc�(� <br />PE SC Received Choclil Amount Dab Permit/ Involta# Well ID# <br />Codes Into 8 Cash Remitted service R uest# <br />EHD 43-06 WELL /PUMP PERMIT <br />4130112 <br />