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613" zL-t <br />ew 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 />EXPIKE5 1 YEAR FROM UATE ISSUED <br />�` JOB ADDRESS <br />- I <br />q( I't/ <br />/ <br />• Y PS-') CITY/ZIP <br />Invoice # <br />CROSS STREET T <br />oi5 k-0 <br />APN �� �_ )L' I PARCEL SIZE Q;7. j) LAND USE # <br />OWNER NAME VAf. <br />�C u Q C <br />_ L� Cl��! <br />pAPPLICATION <br />PHONE l ZO`l) S1 �'tiZ 3 <br />OWNER ADDRESS <br />CITY/STATE/ZIP J\C'•C\ <br />L •J C/O C' \ �J3rJ� <br />CONTRACTOR r" <br />/ <br />T \l l 1 l � �Q �.�C� <br />PHONE 1 Z( � '� (G -'i - <br />CONTRACTOR ADDRESS <br />ItoL (mw'slv-ACII <br />U`J(.k-� CITY/STATE/ZIP <br />0& 03 `7\5�-IJ0 <br />SUBCONTRACTOR ( :I, <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE !C-57 <br />C-61 <br />D-09 ❑ Other NUMBER 12(09 LC' �'� <br />EXPIRATION DATE (` <br />GEOGRAPHICAL INFORMATION: Coordinates X �i7 59 �-K, Y 1 L I . 7lClC' i Township Range Section <br />INTENDED USE I Domestic/Private I Irrigation/Agricultural J Industrial -1 Water Quality Monitoring V'Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Wgier System Name Uontact Name or Phone Number <br />TYPE OF WORK I New Well i Replacement Well L Well Alteration/Modification _I Other <br />Monitoring Well(s) # of wells VSoil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service Well L Out -Of -Service Well Renewal i Cross -Connection Repair <br />New Pump Pump Replacement L Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method i Mud Rotary i Air Rotary Auger Cable Tool I Push Point I Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />i Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched i Steel Plastic i Stainless Steel Other <br />Grout Seal Depth ft ',4Jeat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ;(:Other -s,£„4 ttTi�YV96}�j it <br />Grout Placement Method I Pumped i Free Fall I Other i Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller ' Pump Contractor Other <br />Concrete Pedestal iDimensions: Width ft Length ft Thick in I Christy Box Stove Pipe <br />PUMP i Submersible Turbine I 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 />N(�iVIMUM 24 WDVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7Q697 <br />SIGNED- /�ta C - TITLE/�ftf inla �• / "/Ckt�t��✓ DATE � N a <br />T <br />EP RTMENT USE NL1Y /� <br />Application Accepted By Date Area Employee ID#4wjyp <br />Grout Inspection By Date [ISPECIAL Well Permit <br />Pump Inspection By Date ( ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />PE Sc <br />Codes Info <br />Received <br />ByRemitted <br />hec <br />Amount <br />Date <br />Permit/ <br />vice Request # <br />Invoice # <br />Well ID# <br />4�'772 <br />�) 11 e- <br />111Sve <br />W1�W��i��(1 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />