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Ob WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NVN-KEFUNDABLE PERMIT <br />I:ALL (ZUd) y53 -/by/ FOR INSPECTIONS t=AMIKtS IT YEAR FRO/M�U,AITE ISSUED <br />JOB ADDRESS� <br />CITYIZIPG(� <br />CROSS STREET <br />) �] <br />YJ-L!/c1Vl(J[PN oO J �✓ PARCEL SIZE ��LAND USE APPLICATIONMF <br />OWNER NAME�i �(��0•' <br />T� <br />OWNER ADDRESS 115 L. -OZ <br />1/1J <br />O <br />-0 I `PHONE <br />I -0 /L` ��..}-.• CITYISTATEMP t/V d I <br />V 1 (y V (� 7 I— v�\�- I ✓�'�j%t J�7 <br />CONTRACTOR <br />,(, %`�• <br />- )�l— 3 <br />CONTRACTOR ADDRESS <br />r �PHH�OINE <br />CITY/STATE/ZIP 1 1VI I� 6 �. ✓��� <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE X C-57 X C-61 , D-09 Other <br />CITY/STATE/Z1P <br />NUMBER 3 3 ExPIRATION <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE %Domestic/Private Irrigation/Agricultural : Industrial :: Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If diflererd from OwnerW.1er ame Go ama or u <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Bonng(s) # of bonngs Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method X Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth x-75 ft Excavation I_ in diameter -Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter -U_ in Thickness/Gauge/ASTM Sched (1S )''n n Steel ;(Plastic Stainless Steel Other <br />Grout Seal Depth1 n�ft ' Neat Cement (94 lb bag15-10 gal water) X Sand Cement �� , _sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method X Pumped Free Fall _ Other Retardant / Accelerator (name) <br />PEDESTAL Installed By x Driller Pump Contracto Other <br />Concrete Pedestal Dimensions: Wdth ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible -- Turbine Other HP c 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 />MINIMUM 24 HOUR ADrV�tA-INCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 17 7 <br />SIGNED �yPl-� �i22A-0-e . TITLE Yjr 6 �65S f.Mt DATE 1 / <br />Ir <br />F1 <br />H <br />i■■i■i■i■i-■iiiiliiii�s��s®®�c�iiiiii�al��siiiiii <br />■■■■■■■■■e_iii■■■i■��■rs■■■■■■■■■■■■I■■■■■■■■■■■■■ <br />■■■■■■■■■■■■I■■■ICI■■■■■■■■��I!R!w■■I■■■■■■■■■■■L�LtI .. <br />R4' .. i .:. <br />a - - <br />PE SC ReceivedChec <br />Codes Info B <br />ash <br />Amount Date Permit/ Invoice# WellID# <br />Remitted Service Re uest# <br />136 <br />EHD 43-08 <br />4130112 <br />I� <br />WELL !PUMP PERMIT <br />