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WELL/PUMP PERMIT <br /> SAN JOAGUIN COUNTY ENWRONMENTAL HEALTH DEPARTMENT t W8 EAST HAZELToN AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �a70 <br /> Jae AooPcss (,�[���J1..- ��. � �� � <br /> p D <br /> CROSS STREET })�j( !G APN267"' 4ARCEL SIZE r LAND USE AIPPiICATION# A <br /> m <br /> OWNER NAME 111-1 GS -u7'L.C-R=�--�PHONE <br /> OWNER ADDRESS S. <br /> 962 tr� <br /> CONTRACTOR �f-' <br /> �r PHONE <br /> CONTRACTOR ADDRESS J J� Cn1MA-n1W. j!j5r� <br /> .SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEfZIP <br /> ^ <br /> LICENSE C-57 C-61 D-09 Other NUMBER ) I EXPIRAT10N DATE��_ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y_ Township_ Range Section <br /> INTENDED USE DomesticlPnvate IrrigationlAgricullural Industrial Water Quality Monitoring Soli Sampling/Characterization <br /> Public Water System <br /> If ddfumnl lmm Owner Water YS em ame C-I.Ct Name or Phone Mmber <br /> TYPE OF WORN 'XNew WeII Replacement Well Well AlteralioniModikatinn Other <br /> Monitoring Well(s) #of wells Soil Bormg(s) n°}6on ys Geotechnical a of barings <br /> Out-Of-Service Well Out-01-Service Well Renewal Cross-Connecfion Repair <br /> New Pump Pump Replacement _ Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)( Mud Rotary Air Rotary Auger i Cable TOOL Push Point Other <br /> Proposed Well Depth 3 7 ft Excavation�Z�in diameter Open Bottom Gravel ParVGmvel Size in diameter <br /> Conductor Casing N in diameter ! Conductor Casing Depth N..- ft <br /> WeII Casing Diameter_Lin ThicknesslGaugeIASTM Schad^:C f Z\ Steel 7y Plastic Stainless Steel Other <br /> Grout Seal Depth I M It Neat Cement(941111a8915-10 gal water) Sand Cement_ r3 sack mixr7 gal water <br /> Bentonite(20%solids) Other <br /> i <br /> Grout Placement M!!t2dj Pumped Free Fall Other Retardant I Accelerator(name) <br /> PEDrsrAL Installed By x Driller Pump Contractor - Other <br /> Concrete Pedestal Dimensions:Width it Length=ft Thick in - Christy Box -Stove Pipe <br /> PUMP Submersible Turbine Other HP—A— Pump Sel�-?--O R Standing Water Level_-�_ft <br /> f 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 /> FVIINIMUM 24 HO RAD CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED -" / •r+ TITLE "4 "V-"g-r DATE op <br /> I <br /> I <br /> f L <br /> I r <br /> III f - <br /> I <br /> pL <br /> 1 .1 L ayiff- <br /> DEPARTMENT U E O LY <br /> I V <br /> r rAIL LLO� <br /> Application Accepted By_ �D.te 7 [ Area t - Employee 6# <br /> Grout Inspection By Date L SPECIAL Well Permit <br /> Pump inspection By pate U WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth h <br /> COMMENTS -✓"SLFhiEO-A -A-(INL L G1 r56MLAtEA �netA_` Y=,SnV&- <br /> PE SC Received Check#i AmOUN1 Dale PertmN Invoice# WeII ID# <br /> Codes Info B Cash Remitted Service Request Y <br /> Lf3l�V gs-n v, 3 r 8- ` <br /> 34 r° 3 <br /> EHO 43-06 WELL!PUMP PERMrr <br /> I 4134f12 <br />