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r r J <br />WELL/PUMP PERMIT <br />SM JOAQUIN COUNTY ENVIRONMENTAL HEAFTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />ADDRESS �""1 1 / 1 '•^a 1�.d5—®Ti^P� `!//'��+`l�''�.: r< CirY21P •..�S 4e'!•.:�rv%�' M� l ! I' <br />SS STREET K/ U 1 r 1 U `J {�-� �N 1 V U 2-C! 0 PARCEL SIZE ��LMD USE APPLICATION # <br />IER NAME J cl v .� r '}�-1 1 1(1 !g u 1 � z /t PHONE q <br />IER ADDRESS 9 36 / ' Q 5S ✓1l CA CrTY/STATE21P `�'� n % {� / 5 2 f Z <br />TRACTOR v ).., lrlj r,' _ ,Vfee& <br />s .. uP+ PHONE...n )r FIT • f +CY <br />TRACTOR ADDRESS a CITY/STATE21P <br />:ONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CrrY/STATE^MP �) Z <br />LICENSE 457 , ` C-61 i-, D-09 .` . Other NUMBER - �T < EXPIRATION DATE -7 " J 1 <br />GEQORAPHICAL INFORMATION: Coordinates X Y Township Ranga Section_ <br />NTENDED USE mestic/Private I Irrigation/Agricultural , Industrial I Water Quality Monitoring I Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. Water SYMM Name con aCt Name or one um r <br />TYPE OF WORK Y -New Well - Replacement Well F Weli Alteration/Modification Other <br />MonitoringWell(s) #of wells ; Sol] Boring(s) #of borings ( Geotechnical #of borings <br />Out -Of -Service Well i: Out -Of -Service Well Renewal Cross -Connection Repair <br />VNew Puma Puma Reni2catment I- Pumn Renair Raises Weli Casinn <br />Drilling Method ' Mud Rotary Air Rotary Auger ' Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter ; Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing In diameter I Conductor Casing Depth it <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 7 Steel C" Plastic Stainless Steel - Other <br />Grout Seal Depth ft Neat Cement (94 /b bagf5.10 gal water) Sand Cement Sack mix/7 gal water <br />"' Bentonite (20% solids) " Other <br />Grout Placement Method " Pumped ( Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By ; : Driller "' Pump Contractor Other <br />C Concrete Pedestal i -Dimensions: Width it Length ft Thick in Christy Box Stove Pipe <br />PUMP ubmerslble . Turbine Other HP r' k : ° 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 />MINIM!!e�UVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9531 97 <br />SIGNED TITLE l.�r t ""u,F" (�t� �$ DATE 1 ` / & <br />m <br />mX <br />EPARTMENT �USE ONLY C <br />Application Accepted By Date / U �� f Area Employee ID# 00 n y <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By V Date i i I 0 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC Receivedhec <br />Into B <br />Amount Date <br />Remitted <br />Permit/Invoice # Well IDN <br />Service Re uest# <br />y3Uu <br />OSa Z 73j <br />-7; <br />L4 -7L/ <br />EHD43-0e WELLIPUMPPERMIT <br />4130112 <br />iM <br />gg <br />�y <br />rn <br />