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oz <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNUAHLE�YEZKMII <br />A,LLLL IIZUV) V0.33 -110V1 FOR INSPEGTIUNS CAYIKtS T TZAR FKUMM DATE ISSUED <br />JOB ADDRESS <br />Amount <br />Remitted <br />1/t <br />1 r l (/�{ 1/1/yl' CITY/ZIP 1 01 ✓.'4---000 I � <br />CROSS STREET <br />APN PARCEL SIZF�� AND USE APPLICATION ## <br />OWNER NAME <br />�� <br />l <br />IfIK C, i - —\ PHONE l ^`+✓ L �4-� I�, <br />OWNER ADDRESS S <br />G C7I X, X 1 -KI D- CITY/STATE/ZIP t CA I Cc, s -_a/ <br />CONTRACTOR <br />/�/ 1/f <br />it Iiyo <br />�, <br />PHONE ? I �+ -, 1 -`770 <br />CONTRACTOR ADDRESS �. <br />br =r <br />b CITY/STATE/ZIP �� `� G� � <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP z y/�?, <br />LICENSE kC-57 '.J C-61 LI D-09 Other NUMBER�J� ExPIRAT1oN DATE - 3 v <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Rang@ Section <br />INTENDED USE Y DomestictPrivate E Irrigation/Agricultural I Industrial -, Water Quality Monitoring c i Soil Sampling/Characterization <br />-1 Public Water System <br />If different from Owner: Water System Name C.nt..l N.— or Phone Number <br />TYPE OF WORK I (New Well r'!, Replacement Well F Well Alteration/Modification Li Other <br />i I Monitoring Well(s) # of wells r- Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />n Out -Of -Service Well I- Out -Of -Service Well Renewal n Cross -Connection Repair <br />.- New Pump ❑ Pump Replacement L Pump Repair F Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method X Mud Rotary F Air Rotary Auger Cable Tool r Push Point Other <br />Proposed Well Depth -1-1 p_ft Excavation �� in diameter I i Open Bottom /_Gravel Pack/Gravel Size ��— in diameter <br />0 Conductor Casing in diameter / Conductor Casin Depth // ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schec61SSath Steel "Plastic I_ Stainless Steel i; Other <br />Grout Seal Depth;�� ft I Neat Cement (94 lb bag/5-10 gal water) X Sand Cement il� 3 sack mixl7 gal water <br />L. Bentonite (20% solids) .i Other <br />Grout Placement Method VPumped L Free Fall i i Other L Retardant / Accelerator (name) <br />PEDESTAL Installed By i( Driller L Pump Contractor ,� Other <br />Concrete Pedestal -Dimensions: Width 3 ft Length > ft Thick in Christy Box n Stove Pipe <br />PUMP )(Submersible- Turbine F- Other HP--Iy 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 />MIN M�24 HOUR ADVANCE NOTICE REQUIRED FOR <br />/INSPEC�TIIONS - PLEASE CALL (209) 953-7697 <br />T/1C�" <br />SIGNED ""[�•nL"TITLE (Gi 1 I VS)clinq± DATE <br />y <br />m <br />m <br />0 <br />to <br />N <br />DEPARTMENT US ON Y <br />Application Accepted By Date C Area Employee I D# —Lc-el <br />Grout Inspection By Lr Date ` ❑ SWell Permit <br />Pump Inspection By Date 1 1 ❑ WAIVER Received/ <br />iU <br />Soil Boring Inspection BykDateteConstnlcted Well Depth <br />COMMENTS Jtl ft <br />&'eA <br />PE <br />Codes <br />Sc Received <br />Info B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date Permit <br />Service Re uest# <br />Invoice # Well ID# <br />�� <br />oo 76 <br />F. <br />1003 0 <br />LLSr <br />E <br />�i �, t/ WELL /PUMP PERMIT <br />' ' J� �� wCOD 31000 <br />