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I <br />1.� O <br />WELL/PUMP PERMIT <br />SAN JOAouIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELToN AVENUE - STOCKTON CA 95205 • (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (2 29) 953-7697 FOR INSPECftS, WIRES 1 YYM FROM DA ISSUED <br />JOB ADDRESS 31,7y� <br />0 3 � , J /te l CtrrZP / a + J- <br />CROSS STREET APN 1��� 0 6 1 P RCCEyS.a Iy� LAND USE APPLICATION # <br />TM <br />OWNER NAME �p f7.. V��� �fy19 4L PHONE Y <br />OWNER ADDRESS �///�►1I XA"1 • �lA --ems (FITYISTATE) P <br />CONTRACTOR 1FI <br />HOO <br />NE <br />CONTRACTOR ADDRE$$$$SSSSS- = <br />SUBCONTRACTOR ` <br />PHl)flFy <br />SUBCONTRACTOR ADDRESS ft /STATEIZIP N <br />LICENSE C-57 C-61 D-09 Other NUMBE `r `f T EXPIRATION DATE <br />GEOGRAPHICAL I FO ATION: Coordinates X Y 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 ZJySlefn Name Contact Name or Pnone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) tt of borings Geotechnical a 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 />w�r•n��re��.-r�nu <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 / Conductor Casing Depth ft <br />Weli Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb ba9/5-10 gal water) Sand Cement sack mix17 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 />Concrete Pedestal Dimensions: Width ft L t ft Thick in Christy Box Stove Pi <br />PUMP Poo—Submersible Turbine Other HP Pump Set ft Standing Water Level k <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 />MINA Q,LIM 24 2U-p"It; <br />NOTICE REQUIRED F R INSPCIOOkS - PLEASE CALL (209) 9 3- 697 <br />SIGNED _�f/ TITLE I I l ,!/6] DATE 21 <br />ENVIRONMEN <br />PERMIPSE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />EPARTMENT USE ONLY <br />Date q ' <br />Date <br />Date --6� <br />Date <br />0 <br />D <br />0 <br />0 <br />m <br />w <br />Area JMX Employee ID# / fn e IA <br />_. SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Sc <br />Received <br />Check <br />Amount <br />Date Permit/ Invoice # Well ID# <br />Codes <br />Info <br />By <br />ash <br />Remitted <br />Service Request # <br />Alvo <br />05o <br />dep- <br />�' <br />a4 WP <br />