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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />KInKI 0" <br />- - - "" - a.ra L.L. ZW3 9bJ-/697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS I�LQ� &� <br />Cm21P <br />CROSS STREET r�Q�(- ��f( APN C% I, l } <br />(y Y� PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME (��j�.rp������ /,.�`,I/_ <br />�LaA.M� C"/STATE/ZIP PHONt'7 <br />i C✓�l K1c ✓�( (i(/ <br />OWNER ADDRESS LZ Z • ,.(�IZ /% � ` ' ^1 <br />N' .± [SCJ <br />�=��y�u� ,. L ►.r PHONE ��C�Is�+�� <br />CONTRAC70ft ADDRESS /�=\_4�/'!_��wlN� r' �L CITY/STATE/ZIP C=1 <br />SUBCONTRACTOR �) 1(ia• �1. �ry,PHOONNE _ 4s 3U - <br />SUBCONTRACTOR a <br />ADDRESS gj�)��� ywC�I�TfnY�($TATE/Z`I/P_ \ '"Vv ✓Z ( 1 <br />LICENSE C-57 D C-61 C 0-09 V Other NUMBER' •ass �/ ExPIRATION DATE_ <br />J <br />_.._._. <br />. ,,,,,,,,,,-1— � Y Township_ Range Section_ <br />INTENDED USE L Domestic/Private F Irrigation/Agricultural 1 Industrial n Water Quality Monitoring F Sol] Sampling/Characterization <br />C Public Water System <br />If dlHerenl from Owner a er ys em ame on ac ame or one -15F <br />TYPE OF WORK Y New Well F Replacement Well C Well Alteration/Modification 'QOther X71' <br />❑ Monitoring Wells) tinfr e..:lo...:.,..r..t uoIhodncs n„rw.,,..... <br />_ __.. __....�„• a VCUtCunIllCal <br />F Out -Cf -Service Well E Out -Of -Service Well Renewal C Cross -Connection Repair <br />Drilling Method 'A Mud Rotary F,, A"iir�Rotary C Auger C Cable Tool F. Push Point - Other <br />Proposed Well DepthExcavationin diameter Open Bottom 7 Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter �2- in Thickness/Gauge/ASTM Schad ❑Steel JbPlastic " Stainless Steel Other <br />Grout Seal Depth ��ift '� Neat Cement (94 /b bag/5-10 gal water) C Sand Cement sack mix/7 gal water <br />C Bentonite (20% solids) 0 Other <br />Grout Placement Method A Pumped F Free Fall r- Other Retardant / Accelerator (name) <br />PEDESTAL Installed By L Driller ❑ Pump Contractor p Other <br />C Concrete Pedestal E: Dimensions: Width It Length= ft Thick In Q Christy Box C Stove Pipe <br />PUMP C SubmersibleC Turbine ❑ Other HP Pump Set ft 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 />MIN 4 HOUR ADV E NOTICE REQUIRED F �I N iSlaPEE"C�TIONSS�- PLEASE CALL (209) 95 7p6pyp7 <br />SIGNED TITLE ISS! VV,� \-L DATE• <br />jW <br />D <br />0 <br />°z <br />m <br />y <br />DEPARTMENT USE` 0 LY �/ ��� [ .�.•,/� <br />Application Accepted By Date Area -T / 1. % Employee ID# <br />Grout Inspection By Date El SPECIAL SPECIAL WQII Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Iq§pectlon By 1 Dat Constructed Well Depth ft <br />COMMENTS <br />PE SC Received <br />Codes Info By, <br />Cash <br />Amount <br />Remitted Date <br />Permit/ <br />Service Request# Invoice# Well ID# <br />u <br />- <br />4130/12 <br />WELL /PUMP PERMIT <br />