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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 />CALL 209 953--7697 FOR INSPECTIONS <br />1 YEAR FROM DATE ISSUED <br />JOB ADDRESS �1 <br />n <br />1�1 <br />G`� <br />}/��EXPIRES <br />!"\ D- CITYIZIP r'/\�M9O <br />CROSS STREET JaAnan <br />RD <br />APNOo7,ZbO- <br />3'1 PARCEL SIZE �G&AND USE AAPPPPLIC.I <br />OWNER NAME <br />/ATION�# <br />PHONE VLI1 ` c) 3 ­ 1 I4 <br />OWNER ADDRESS q <br />�a ► <br />'V <br />G t-�+i�a <br />7 t-� / <br />n,. �` V CITY/S7A7EILP <br />p <br />�µ+.M I U �� <br />CONTRACTOR \ 1 G_ 1 <br />`� <br />f 1 1 <br />1 n� `\ <br />PHONE (c� q^ - ;?77A <br />CONTRACTOR ADDRESS <br />nT� <br />P G <br />1�1,�{r?( <br />CITY/STATE/ZJP <br />�\ <br />Gr4' +) C <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CRYISTATE/ZIP <br />LICENSE C-57 <br />-61 <br />D-09 <br />_. Other <br />NUMBER A--✓f---L �ALEXPIRATION <br />DATE <br />GEOGRAPHICAL INFORMATON: Coordinates X Y Township_ Range Section_ <br />INTENDED USE XDomestidPrivate Inigation/Agricultural - Industrial Water Quality Monitoring - Soil Sampling/Characterization <br />Public Water System <br />If different 1— Owner: Water bystem eme Confact N-or 1,hone NuMbW <br />TYPE OF WORK ANew Weil - Replacement Well _ Well AlterationMlodification 1 ^r M Other <br />1 of Mnrcn <br />monitoring vveuls/ 9 or Wells bon tsonngls/ ueotecrinicai <br />n Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />iCNew Pumo - PumD Replacement .. PumD Reoair _ Raise Well Casino <br />Drilling Method -/,Mud Rotary Air Rotary Auger Cable Tool _ Push Point - Other <br />Proposed Well Depth R75 ft Excavation _ in diameter - Open Bottom Gravel Pace/Gravel Size ,�a " in diameter <br />Conductor Casing in diameter / Conductor Casing Depth h <br />Well Casing Diameter G_ in Thickness/Gauge/ASTM Schad C.I ;?Ci) .- Steel APlaslic _ Stainless Steel -_ Other <br />Grout Seal Depth Il G G ft -. Neat Cement (94 Ib beg/5-10 gal water) (Sand Cement 10 S Q < sack mix/7 gal water <br />Bentonite (20% solids) _ Other <br />Grout Placement Method Pumped Free Fall . Other _ Retardant / Accelerator (name) <br />PEDESTAL Instilled By eller Pump Contractor _. Other <br />Concrete Pedestal _.Dimensions: Width -3 ft Length---= ft Thick = in Christy Box Stovs 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 />MINIMU 4 HOUR AWNCE �NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953,-7697 <br />SIGNED �C1' CJ�V �"Y�v TITLEy � (` � � tS i "1e n + DATE I <br />0 <br />W e <br />5 <br />EP RTMENT USE NLY <br />Application AccepteDp(g.� _ Area Employee ID#t� <br />Grout Inspection �%��b+f+T — SPECIAL Well Permit <br />Pump Inspection By DateI r� WAIVER Received l <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS �UJ 390,&� <br />