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WELL/PUMP PERMIT N <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (ZU9) 953-119 t FOR INSPECTIONS �t�F'IKtb T TEAR FROM �j` <br />UAII I: tsbutu <br />JOB ADDRESS I Y I ^1f— k OLCIT a "� " o 5"(J — / <br />CROSS STRE T AC f h / APPN 'I ` C) I PARCEL SIZE • V ((yJ��1 USE APPLICATION -75 <br />Lq <br /># <br />ER AM0 / <br />v`ei� rq <br />OWNER ADDRESS L4 CnYISTATE/ZIP A <br />CONTRACTOR \ Cr)/ � • ' • P& 1 Ll (- " HGONE v <br />CONTRACTOR ADDRESS <br />A—PCA.T ACTnR IV 1 h PHONE PAW <br />_. <br />LICENSE ^^V C -57V V C-61 D-09 Other / NUMBER <br />GEOGRAPHICAL t&-- N! Coordinates X Y Township _ Range Section_ <br />INTENDED USE V Domestic/Private Irrigation/AgricuRural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: water ZSYMSM N8.e Uontad Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boringa of Wrings s) Geotechnical # of borings <br />Out-Of-ServiFe dell Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pum �/ Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <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 diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag45-10 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 />oncrete Pedestal Dimensions: Width ft Len ft Thick in Christy Box §Love Pipe <br />PUMP V Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT 1 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 />MINI�IVIUM 24 HOU�ANCE NOTICE REQUIRED FOR�,jn�SPP/ECTIIoO'(N5 - rPPLEASE CALL (209) 953 647 <br />SIGNED d'f.�N�� TITLE ' " 'yi to r • s ""O DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />EPARTMENT USE ONLY <br />1^ Date 0'17.11 <br />Date <br />4 Date �iwl <br />Date <br />Area S/ 411 Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />3 <br />zI <br />Z <br />SC Received <br />Chec <br />T <br />m M .T1 <br />fl <br />M <br />c X O <br />A <br />C-9% <br />Remitted <br />yam <br />0 SU <br />qq <br />N <br />C= <br />T`~• <br />[7ri <br />M <br />V <br />s <br />R �'e ) r <br />eo <br />Oct 18" <br />4117 NON /7 <br />HEA(rN NON <br />PE <br />SC Received <br />Chec <br />Amount Date <br />Permit/ Invoice # Well ID# <br />Codes <br />Info B <br />as <br />Remitted <br />Service Request# <br />43Y 1 <br />0 SU <br />qq <br />