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r <br />A11- <br />r2- � =� + 5L'w\ to 10 01)'-X <br />WELL/PUMP PERMIT <br />e I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />KUK-KEF UNUAULL rtKMI I <br />t,ALL ILU%P) J04 -/0A/ 1 -UK IN5PbG I IUN5 <br />tA,rIKGJ T TtAK I -HUM UAIt IbbUtU <br />JOB ADDRESS <br />A <br />�'1 M (� �; \ V CITYILP <br />.� C [� <br />t� <br />CROSS STREET `V K -t' Yl Y)C-4' <br />' C <br />— �ZO— O PARCEL SIZE LAND USE APPLICATION # <br />QDAPNPI /J <br />Ti, <br />TT <br />OWNER NAME -C <br />� if I/ V <br />PHONE <br />OWNER ADDRESS C/1 C1 <br />^�, 1 <br />`� 1 \ 1 <br />l-� <br />(f; is t_`, 1\ 1 J CITY/STATEMP <br />L C'!J 1 C. 1 CA C7 "1 c <br />CONTRACTOR �f :!,' lt' `� <br />Q i <br />I I Y) LI <br />PHONE L —7 %Li <br />CONTRACTOR ADDRESS P' i - <br />C, f <br />4-2 CITY/STATE/LP <br />1-7, <br />(-Q Q I 't I C -\ <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />C-57 C-61 D-09 <br />CITY/STppATEE�/7JP <br />NUMBER 2`I - -7 ] -; EXPIRATION <br />_51_ i <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE XDomesticlPrivate _ Irrigation/Agricultural Industrial i s Water Quality Monitoring -' Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: WaW Syt.. Name cont. ema or ne um r <br />TYPE OF WORK New Well -! Replacement Well Well Alteration/Modification - Other <br />G Monitoring Well(s) # of wells Soil Boring(s) s of Iwnngs Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal - Cross -Connection Repair <br />A o1 bonngs <br />Drilling MethodXMud Rotary ^ Air Rotary Auger _- Cable Tool _. Push Point Other <br />Proposed Well Depth ft Excavation i in diameter r''. Open Bottom NGravel Pa&JGravel Size 24 _ in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in ThicknesslGauge/ASTMSchad C.l,2cel - Steel Plastic _ Stainless Steel - Other <br />Grout Seal Depth '1,141 It - Neat Cement (94 lb bag.15-10 gal water) 'Y Sand Cement) C - j sack mix/7 gal water <br />_I Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall i Other '_ Retardant / Accelerator (name) <br />PEDESTAL Installed By )(Driller Pump Contractor:- Other <br />Concrete Pedestal r Dimensions: Width �_ ft Length R Thick in Christy Box Stove Pipe <br />PUMP Submersible - Turbine - Other HP_-; Pump Set ft Standing Water Level `-1 r. 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 HOURJ ADVANCE NOTICE REQUIRED FOR T 171 INSPECTIONS - PLEASE CALL (209) 953-7697 <br />I <br />SIGNED � � JC1/��;;:; 1C4 �. TITLE ' CC -e rA <br />, C DATE 'C' ' <br />yG <br />m <br />0 <br />A <br />m <br />YME!i4 <br />w1e6elveD <br />61 0-'1 JA <br />COVN" <br />.A EN Ard- <br />DE p'vt <br />µEpLTH <br />Dj AR MENTI SE ONLY A <br />Application Accepted ate Area Employee ID#�J <br />ii <br />Grout Inspection J - ate r 7 SPECIAL Well Permit YF. <br />Pump Inspection By N Data r, -1 WAIVER Received <br />Soil Boring Inspection By D to Constructed Well Depth ym <br />/Y^ <br />AMENTS ill i / /7l �r�l-) ljr % . nE � _ I L f'�l_A IT A / � {�G�() ��! 1�c L' <br />EHD11� 70 (% 101 •I'� <br />1/30/1212 <br />WELL /PUMP PERMIT <br />l IN <br />Too ATIA <br />EHD11� 70 (% 101 •I'� <br />1/30/1212 <br />WELL /PUMP PERMIT <br />