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r, ' <br />WELL/PUMP PERMIT I- / 1, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />CAtLL 209 953.7697 FOR INSPECTIONS <br />NON-REFUNDABLE PERMIT CALL <br />LXI'IKtb 1 TEAR FROM DATE ISSUED <br />a`-' ^Ynl aT e <br />�T� <br />.4� <br />JOB ADDRESS / <br />CITYIZIP <br />"�' <br />/O� <br />�f <br />CROSS STREET /"� S APN IO -- <br />f <br />ZZ b'f` PARCEL SIZE OO <br />�cANDD USE AP <br />ro l <br />OWNER NAME ✓ t j 1-,4,4IN 14',1 � <br />OWNER <br />/I** <br />t 01�� f <br />PHONE / `wJ 7(I e <br />J <br />OWNER ADDRESS gos 7 j"'w'04. �� <br />Cm'/STATE/ZIP <br />�1 /J <br />'CONTRACTOR (y��4,..0���7"� J`�J.iY /i1 { P //� <br />PHONE (120 9J 9*1-r- 17 745- <br />�tJ <br />CONTRACTOR ADDRESS ! L.1 QL/ G 'f'MO'Lr <br />"T CrTY/STATE/ZIP <br />C-. `�da'� 9s—al -7 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CRY/STATE/ZIP <br />LICENSE , LI C-57 j't-61 I' D-09 I Other • <br />NUMBER • 7'"Y-3 <br />E%PIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />NTENDED USE I%Domestic/Private 1 Irrigation/Agricultural ! i Industrial I I Water Quality Monitoring I Soil Sampling/Characterization <br />I Public Water System <br />If different from Owner Wat., Y. em ame contaCt Na" or Phone Numner <br />TYPE OF WORK I New Well I I Replacement Well I Well Alteration/Modification I I Other <br />1 Monitoring Well(s) # of wells • I Soil Boringq of borings s) I Geotechnical 9 of borings <br />I Out -Of -Service Well I Out -Of -Service Well Renewal I I Cross -Connection Repair <br />I New Pumn bdumo Replacement I PumD Repair I I Raise Well Casing <br />Drilling Method I I Mud Rotary I I Air Rotary i I Auger I I Cable Tool Push Point I I Other <br />Proposed Well Depth ft Excavation in diameter LI Open Bottom i.I Gravel Pack/Gravel Size in diameter <br />..I Conductor Casing in diameter / Conductor C ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sch i I Steel I I Plastic f 1 Stainless Steel f Other <br />Grout Seal Depth ft II Neat C 941b bag/5.10 gal water) fl Sand Cement sack mix/`7gal water <br />CI Bentonite (20% solids) her <br />Grout Placement Method II Pumped a Free Fail I Other I1 Retardant / Accelerator (name) <br />PEDESTAL Installed By I I Driller I I Pump Contractor I I Other <br />Concrete Pedestal f IDimenslons: Width ft Length It Thick in I Christy Box CI Stove Pipe <br />PUMP Subme riblet 1 Turbine I I Other HP Pump Set C ft Standing Water Level O 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 OTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />� <br />SIGNED TITLE '" N DATE 3 /` / <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />N <br />ENT <br />PE SC Received <br />Codes Info B <br />MEN <br />'Amount Date Perm fU <br />emitted Service Re uest # Invoice # Well ID# <br />41 -)IL <br />Data <br />Area Employee ID#� <br />Date <br />❑ PECI Well Permit <br />Date <br />❑ WAIVER Received <br />Date <br />Constructed Well Depth <br />ft <br />PE SC Received <br />Codes Info B <br />Che <br />Cash <br />'Amount Date Perm fU <br />emitted Service Re uest # Invoice # Well ID# <br />41 -)IL <br />EHD 43-D6 <br />4130112 <br />WELL /PUMP PERMIT <br />I <br />