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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 CALL 209 953-7697 FOR INSPECTIONS // EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> y„ f] , 6�t IAJ. �� ��J f-0101 `7 J.2get m <br /> JOB ADDRESS '7r7'prG`11�y � CrrvIZIP <br /> D <br /> CROSS STREET r d02N ro/J APN ( 5 001�11 <br /> PARCEL SIZE { LA D USE <br /> �,APPLICATION# m <br /> OWNER NAME f{"�C-�T��7 y/ }� r^NE _/F —P 3- 1 34th <br /> OWNER ADDRESS P,0, f DX �16(`J CITY/STATEIZIP 9/�1/�rj 1z-g,6/? G9 G{y 120 <br /> CONTRACTOR G112,,15';-r --oQl2 -QW y6 <br /> �,W12l71- PHONE Sle-2q3-e73&0 <br /> q - 73Jr 0 <br /> CONTRACTOR ADDRESS -2.2'7 LOMMG1ZGG�/'�(I�FG� CITYISTATE21P NAVW4hL7 CAI. 41li- 45 <br /> SUBCONTRACTOR 612E66 1212111IZV&fi'I ZSr1616 PHONE '?!.ri-3 13-L 8jq2 <br /> SUBCONTRACTOR ADDRESS 'l5D NOwE Ri CIT1Y/STATE/ZIP tji&1./pjEZ u9. fllls'5 3 <br /> LICENSE X C-57 Ll C-61 [ D-09 E',Other NUMBER .1T}� EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y ?t ownship Range Section_ <br /> INTENDED USE Domestic/PrIvate rIrrigation/Agricultural Industrial r,Water Quallty Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. water bYSIAM Name one ame or vnone NUMDer <br /> TYPE OF WORK New Well 0 Replacement Well r Well Alteration/Modification a Other a ATIaIJntG, <br /> Monitoring Well(s) #of wells Soil Borings) #of boring$ ❑Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> i�New Pump n Pump Replacement Pump Repair U Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 11 Mud Rotary C.Air Rotary C Auger r Cable Tool Push Point r Other <br /> Proposed Well Depth OD It Excavation 10 11 in diameter Open Bottom r Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel o Plastic Stainless Steel I!Other <br /> Grout Seal Depth C/ti ft j(Neat Cement(94 Ib bag/5-10 gal water) [7 Sand Cement sack mix)`7 gal water <br /> -i Bentonite(20%solids) Other <br /> Grout Placement Method 4p Pumped Free Fall ['Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑Pump Contractor D Other <br /> Concrete Pedestal[IDimensions:Width ft Length ft Thick in n Christy Box Stove Pipe <br /> PUMP ❑Submersible C Turbine CI 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED�1 TITLE l,Owl,rMi/L 70" Egag @"g2 DATA <br /> OA <br /> zm <br /> wa <br /> zMa <br /> D=G <br /> INSTALL DEEP WELL ANODE (E)POWER POLE U' Cx Q <br /> ' <br /> A C � oz <br /> R REPLACE(E)RECTIFIER z W <br /> DET 1 Q = <br /> c DET 4 rn <br /> \ _ KILE RD. — <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 31 Ili, 1, Area 0 �1 Employee ID#lr�� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By A _ Date ^^ 2 ❑ WAIVER Received <br /> Soil Boring Inspection By D to 1—''3 Constructed Well Depth ft <br /> COMMENT <br /> 6 �a ef, C <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# WellID# <br /> Codes Info B Cash Remitted Service Request# <br /> Zb 3-n-16 52V7H3R 09003-701 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30112 <br />