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IC' •` CGS � �" �,: <br />WELL/PUMP PERMIT <br />r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />@R A <br />NON-REFUNDABLE PERMIT CALL (2 09) 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />33 ^' 3Ch Qr <br />E <br />Coll 9 5aso <br />Joe ADDRESS v' 1 V • l Vj• CFTY/ZIP <br />l � <br />CROSS STREET P6 1 T i C r R17- APN O - 4A0PARCEL SIZE <br />LAND USE APPLICATION # <br />OWNER NAME (✓J Jrr <br />PHONE <br />OWNER ADDRESS CITY/STATE/ZIP <br />j <br />�.U� �ZE /wu- <br />CONTRACTOR e <br />79 <br />PHHO�NE�-+�/+'' <br />^9 <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />—PHONE <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS CITY/STATE/?JP <br />�' ) <br />LICENSE C-57 C-61 D-09 Other NUMBER -- 00. <br />EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE DomesticlPrivate Irrigation/Agricultural Industrial Water Quality Monitoring ! Soil Sampling/Characterization <br />Public Water System <br />If different from Owner, a er Sytern Nerne o a eme or one um <br />rYPE OF WORK New Well Replacement Well :.: Well Alteration/Modification Other <br />Monitoring Wells) # of wells Soil Bodng(s) # of bonrgs Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal i ! Cross -Connection Repair <br />Drilling Method -AMud Rotary i Air Rotary I Auger Cable Tool - Push Point Other <br />Proposed Well DepthV901 ft Excavation IQ in diameter Open Bottom Gravel Pack/Gravel SizeVA - in diameter <br />Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter -(�- in Thickness/Gauge/ASTM Schad C1 ado _i Steel (Plastic i Stainless Steel ❑ Other <br />Grout Seal Depth 100 ft i Neat Cement (94 lb bag/5-10 gal water) i)(Sand Cement 10.9 sack mix17 gal water <br />i Bentonite (20% solids) i Other <br />Grout Placement Method Pumped ! i Free Fall I , Other Retardant / Accelerator (name) <br />PEDESTAL Installed By )(Driller Pump Contractor I Other <br />';KConcretePbdestal iDimensions: Width �J ft Length ft Thick in ' Christy Box Stove Pipe <br />PUMP Submersible Turbine � Other HPr Pump Set ft Standing Water Level ft <br />2- <br />1 <br />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 />MINIM � 224�HOUR <br />tADVANCE <br />�NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)Q95 -76 7 <br />SIGNED "l�G�'C /7 `r�t/"o'o� TITLE V ict �Sta'en+ DATE O <br />Application Accepted/By, <br />Grout Inspectifn-Cj� <br />Pump Inspection By <br />Soil Bonn I pection B <br />COMMENTS <br />D <br />0 <br />m <br />N <br />E�,p RTMENT VSE/ONLY <br />10 <br />Date Area K "l EmployeelD# ✓`� <br />Date ❑ PECIAL Well Permit <br />Date I WAIVER Received <br />Date Constructed Well Depth 10 ft <br />PE SC Received <br />Check#/ <br />Amount <br />Date <br />Permit/ <br />Invoice# Well ID# <br />Codes Info B <br />Cash <br />Remitted <br />Service Re uest# <br />i <br />Lj -Y'7 <br />j <br />�.U� �ZE /wu- <br />`� <br />✓ <br />EHE) 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />