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I' WELL/PUMP PERMIT I <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT ,(L;ALL ZU9 953-7697 FOR INSPECTIONS tAl'lKtb I YEAR FROM DATE ISSSUED <br />JOB ADDRESS 3 S CKI til . CITY/ZIP Vf/l*i VWui6 / <br />CROSS STREET/tX,U Z C,I�/ APNr O� �(1 �i `'1 PARCEL SIZE 1 C� • I C LAND USE APPLICATION # <br />OWNER NAME ����a���i� zkkc' Lf""m�\ zkkc' l f""mgege PHONECZC�A n��S�- S��� <br />OWNER ADDRESS 5 VS 1 %Ct be P\Ue nk� \ Q. CITY/STATE/ZIP <br />CONTRACTOR, ` V • ,(L(� O 1'1 PHONE <br />CONTRACTOR ADDRESS quZ lY1dUScC1AI WA`I CITY/STATE/ZIP (,W L CA n521-10 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ✓C-57 C-61 D-09 Other. <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER (��1 Cl L I EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X '2)1Y'y�7i� 5') V3 Township Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells V Soil Boring(s) I # of borings x Geotechnical _# of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />Drilling Method Mud Rotary Air Rotary ✓Auger Cable Tool Push Point Other <br />Proposed Well Depth qO ' ft Excavation 0 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 Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement 94 Ib bag,15-10 gal water) Sand Cement sack mix/7 gal water <br />P. <br />Bentonite (20% solids) C n <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP 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 <br />ADVANCE NOTICE <br />^REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7�697G <br />SIGNED �� //�A //fir TITLE 5 �n �r ��`� 4�f DATE 52 JU// I7! <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By /VV"hE�i <br />COMMENTS <br />EP RTMENT U E ONLY <br />Date <br />n�+e <br />Date < / <br />Date & 7 '7e? <br />Area Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />T <br />1 <br />m <br />D <br />0 <br />v <br />rn <br />m <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />!� <br />zzz <br />s <br />Wp bo 3g 3�Z <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />