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D <br />Nhal Scan 101t, 1 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />YEKMII (.ALL <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME 1 1 IF <br />OWNER ADDRESS <br />CONTRACTOR C Jf•/F,/-/F`, <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE KC -57 <br />C-61 D-09 <br />APN <br />U3J-f D%1f 1 -(JK IN5PE(; I IUNS <br />ANve- Crn <br />��I1.1 1 D-RCEL SIZE/Q , T.iXAND USE APPLICATION # <br />PHONE vo <br />CITY/STATE/ZIP <br />lL- -P' ONE SO <br />CITY/STATE/Zip kk4b, C-4- ?-a( <br />PHONE <br />MAYIKIIZO "1 TEAK FKUM UAI t IJJUtU <br />CI/TY <br />/STATE/ZIP ^- j <br />Other NUMBER 1 I C � � 2 � EXPIRATION DATE L / z <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br />JTENDED USE *-Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name LORI ame or one Number <br />TYPE OF WORK(New Well Replacement Well Well Alteration/Modification Other <br />tt of borings Geotechnical #of borings <br />Monitoring Well(s)_ # of wells Soil Boring(s) <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <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 (941b bag15-10 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 ft 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 />„�AAI1VIMUM 24 COOrRftE <br />NOTICEREQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />StrNFo��! r1. F`� f\. _ TITLE DATE <br />ppY�(VE� <br />RECE <br />ApR � 3 217 <br />� y,}1JOA4UIMEti� <br />PWRON <br />1.}iDEPAR" `r DE A TMENT U E ONLYVMXL <br />Application Accept < Dale s4I� Areas Employee ID# <br />Grout Inspection By Dale LSPECIAL Well Permit <br />Pump Inspection By Date t(a^j,NAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth It <br />COMMENTS <br />rA <br />D <br />O <br />0 <br />m <br />N <br />PE SC Receivedhec <br />Codes Info B s <br />Amount <br />Remitted <br />Date <br />Permit/ Invoice # <br />Service Request # <br />Well ID# <br />�J347 <br />5,0.007 ?.1 <br />W11tq(0 <br />EHD 43-06 WILL IPUMH H-11 <br />4130/12 <br />