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Y -Cv <br />�:O& WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />Cr')CALL <br />CIII CITYIZIP PCll ✓j ;/�� <br />4QO -✓ <br />CROSS STREET <br />PN 4i PARCEL SIZE AND USE APPLICATION # <br />OWNER NAME �jI �in'' <br />i-I.}.c <br />�tr1 <br />OWNER ADOREss I I5 W <br />n,�1 <br />I PHONE <br />V 1 V Ci A L t • 2a CITY/STATE/ZJP t/U I ✓'dlrt�]l )�7 <br />CONTRACTOR <br />�[/�'(J�\ ?`�� <br />PHONE <br />CONTRACTOR ADDRESS <br />CRY/STATE/ZLP (eta l� Glc 951o32— <br />15b32SUBCONTRACTOR <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CRrYI/STATE/LP <br />- - <br />3 <br />LICENSE , C-57 C-61 <br />_ D-09 _ Other NUMBER I EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE Domestic(Private - Irrigation/Agricultural - Industrial - Water Quality Monitoring Soil Sampling/Charactertzation <br />Public Water System <br />If different from C) !7 Water 5yalam Nam ContaCt Nam or u <br />TYPE OF WORK I(New Well - Replacement Well _ Well AlterationlModihcation C Other <br />Monitoring Well(s) # of wells _ Soil Boring(s) "bonngs Geotechnical %a(nodnas <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 X Mud Rotary Air Rotary Auger - Cable Tool Push Point Other <br />Proposed Well Depth ?-I5 it Excavation _L)--- in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter / in Thickness/Gauge/ASTM Sched (1� �-b n _- Steel (Plastic Stainless Steel Other <br />Grout Seal Depth I ft -: Neat Cement (94 lb bagl5-10 gal water) X Sand Cement �j� ,�_ sack mixl7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method X, Pumped Free Fall -- Other Retardant / Accelerator (name) <br />PEDESTAL Installed By )S Driller Pump Contracto Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in - Christy Box Stove Pipe <br />PUMP Submersible- Turbine Other HP -0--a Pump Set ft Standing Water Level ft <br />1 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 ` <br />SIGNED =�a�-e � �tlV LNi'C TITLE Vi/o �Y (1�+� t t DATE � 17 <br />U) <br />m <br />D <br />O <br />X <br />N <br />iiii--iiii■;ii-----c-iiiiii�l-a��iiiiii <br />■■■■■■■■■■■i■■■i■■■■■■■■■■■ri■o■■i■��■■■■■■■■■■ <br />6 2017 <br />■■■■■■■■■ee,■i■■■i■■■■■■■■■■��■■■■i■■■■■■■■■■■■■ <br />■■■■■■■■■■■■i■■■ice■■■■■■■■■c■r��l■■i■■■■■■■■■■■tea .. • <br />■■■■■■■■■■■■i■■■i■■■■■■■■■■■■n+e■��■■■■■■■■■■■� • <br />e - - <br />PE SC Received <br />Codes Info B <br />Chec <br />ash <br />Amount Date PertnlU Invoice # Well ID# <br />Remitted Service Request # <br />7/4 Vw'p CC>J <br />(c-7 <br />EHD 43-08 r WELL /PUMP PERMIT <br />4/30/12 <br />