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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 />NUN -REFUNDABLE PERMIT <br />GALL ZU9 953-1691 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />1 <br />Tr�1(, <br />JOB ADDRESS <br />h CITY/ZIP t/ t ��-�- <br />t <br />O <br />CROSSSTREET <br />1 (J` PARCEL SIZEJ.41LAND USE APACATION <br />OWNER NAME <br />yyAPN)50-o <br />PHONE <br />� <br />OWNER ADDRESS SCA iry Q <br />CITY/STATE/ZIP <br />CONTRACTORL'y' <br />f_14 <br />`- O N-) `It L`I_�._ PHONNrEna` .�1, <br />O <br />CONTRACTOR ADDRESS I)1V 1f <br />[► <br />(.' / � '`�A <br />yr4 h A Yi A CITY/STATE/ZIP Vh -1 J Jam% <br />CITY/STATE/ZIP <br />C-57 L C-61 U D-09 U Other NUMBER q —7 EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X I Y Township _ Range Section_ <br />INTENDED USE Domestic/Private 7 Irrigation/Agricultural ❑ Industrial 7 Water Quality Monitoring C Soil Sampling/Characterization <br />U Public Water System <br />If different from 0 Water System Nam L;ontadt Name or Rone NUMber <br />TYPE OF WORK )(NewWell L Replacement Well U Well Alteration/Modification U Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) A or oonngs ❑ Geotechnical IF or Donngs <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />U New Pump L Pump Replacement U Pump Repair U Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method r Mud Rotary C Air Rotary C Auger J Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth200 It Excavation 13— in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter <br />n Conductyr Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter W in Thickness/Gauge/ASTM Schad n Steel n Plastic n Stainless Steel -1 Other <br />Grout Seal Depth 100 C Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br />Bentonite (20% solids) L Other <br />Grout Placement Method XPumped ❑ Free Fall C Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By J Driller C Pump Contractor 7 Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Plpe <br />PUMP n Submersible) Turbine C Other HP Pump Set ft Standing Water Level ft <br />I HEREBY F HAT I HAV REPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN NT`j C�RDINANC STAJE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURV)IT A T E WITFVYRE CfLIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />S <br />24 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />Pt -eck#/ <br />Codes I Ipfo I By Cash <br />EHD 43-0B <br />4,30/12 <br />RED FOR` INySP�E�CTIONS - PLEASE CALL (209) <br />TITLE O O�'V{ 1 pr( "-tV /_ DATE <br />_o <br />A <br />EPA TMENT USE ONLY <br />i <br />to 77 Area Employee ID# <br />LS, Date ❑ PECIAL Well Permit r <br />Date ❑ WAIVER ReCelVed (� ` <br />Date ruct ell Depth ft C� W <br />;;r ti° <br />-- - '7L <br />a I Date I Invoice# WeIIID# <br />WELL /PUMP PERMIT <br />