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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 466-3420 <br />NUN-KEFUNDABLE PERMIT <br />UALL (ZUV) 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />`' i�� <br />C I O C1 CR3 Z1J <br />JOB ADDRESS ^` `-' <br />l <br />Cm21P <br />�- rl <br />- <br />� <br />CROSS STREET 4 U <br />APN �(J4/ <br />� <br />PARCEL SIZE <br />LAND USE APPLICATION # <br />OWNER NAME <br />'J <br />` �yj� <br />_ ` -v <br />^� <br />�i Lv 1�Jy�J <br />7CRYISTAI'EILIP <br />1P�HON`E� ll�/�' 1`n� <br />��i% <br />OWNER ADDRESS <br />L <br />Z <br />/ <br />4- �(j,l V v �JcJ <br />// <br />CONTRACTOR 7.y (I (( i/A-' O2oil) <br />J % 1( <br />/i)C <br />� <br />�//Y' <br />(t� <br />PHONFiM— (�t 4�/.J r <br />CONTRACTOR ADDRESS .� i� 1 k'� <br />) r p /'� In [.0 <br />CITY/STATE/ZIP h 2A L b 11 � L �tS: i C 4 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CrrYISTATE/ZIP <br />LICENSE C-57 C-61 D-09 <br />Other <br />NUMBER I. <br />EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />4TENDED USE - Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring 4 Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact ameorPnone NumDer <br />TYPE OF WORK New Well 11Replacement Well i Well Alteration/Modification 1.Other <br />Monitoring Well(s) # of wells C Soil Boring(s) # of borings Geotechnical # of bonngs <br />Out -Of -Service Well Out -0f -Service Well Renewal Cross -Connection Repair <br />'*./ww ruuiy runty—pid—UHL rwnp mupdu rcdue uvea �dsuiy <br />WELL CONSTRUCTION <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 />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel '" Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5.10 gal water) Sand Cement sack mix/7 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 fl 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 />INIMU" HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-767 <br />SIGNED - TITLE i..'�' i j,( if.Jc�' DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS S I' r p l <br />r <br />EPt RTMENT JUSE <br />�/ N Y <br />Data <br />Dale <br />Date <br />t, n <br />Date n <br />y <br />D <br />Air <br />r o,, QU()v 8 <br />ryQFp��r qcN��„ <br />�%Fiyr <br />Are ae=� Employee ID#y��Etll� <br />IJ SPECIAL Well Permit <br />O WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received <br />Codes Info By <br />Cash <br />Amount D e Permit/ Invoice # Well ID# <br />Remitted Service Request III <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />