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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 /> NON-REFUNDABLE PERMIT �t CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOR AnDRGSS �`70 J Qd�J�n 04 crrrmP M 51;:2 5 <br /> �{-tel ff D <br /> CROSS STREET /3rd G/c /PN �16 . A I i'� — CEL$ : V o <br /> W17—� G� �rLA,NI D USE APPLICATION# p <br /> OWNER NAME PHONE <br /> u' <br /> L+ PH <br /> OWNER ADDRESS <br /> CONTRACTOR a- r f PHO/NYE '�Gs/ta/��s4s <br /> CONTRACTOR ADDRESS r.15 c. Cfry/STATE/ZIP �` <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER-4��9 47 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE XDOmesliC/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Wate,Sy—Narn. on a ame or rw um r <br /> TYPE OF WORK XNew Well Replacement Well Well Alleration/ModifiCation Other <br /> Monitoring Wells) #of wells Soil Boring(s)s #of borings Geotechnical #of bodngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection 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 5 '7 l7 ft Excavation I"T in diameter Open Bottom Gravel PwWGravel Size in diameter <br /> Conducto`_r Casing %"',, in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter_S/�in Thickness/Gauge/ASTM Scheid C Q)I_3�j S y\Plastic Stainless Steel Other <br /> Grout Seal Depth Dnp It Neat Cement(94/b bag/5-10 gal water) J1 Sand Cement i3 SI( sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method IPumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By x Driller Pump Contractor Other <br /> �(Concrete Pedestal Dimensions:Width n It Length ft Thick in Christy Boz Stove Pipe <br /> PUMP X Submersible Turbine Other HP!_ Pump Set ft Stf{ <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. 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 /> INIMUM 24 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED 1'f �� TITLE i• " <br /> DATE <br /> --------------- <br /> ' PLS <br /> .;40I r <br /> AL <br /> r <br /> PL <br /> IA <br /> J <br /> Q DEPARTMENT UqE O LY <br /> � r r <br /> Application Accepted By Date Area `� Employee ID#�t E <br /> Grout Inspection By 6 j Date D ❑ SPECIAL Well Permit <br /> ( Pump Inspection By6tAtc. Date JJIL2,6T2 i:>-10 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depthl. ft <br /> COMMS TS yl.CrN t. v <br /> SC Received Chadd! Amount Permit/ <br /> Fi& <br /> Info Cash Remitted Date Service R uest# Invoice# Well ID# <br /> 18D 3 X361. 3 r 7(c 9 <br /> 'f38tJ coo -70-n) I (ZCC <br /> t4;5. 3 <br /> eo4ace <br /> 4/90ft2 W ELL HUMP PERMIT <br />