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04IL-11 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE rPERMIT 17, CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS A 1'�r c`-' '^ ✓ 1 �J JA \,i j �G CITY/ZIP L t n cA e n /�1 llE;"' 31GJr_ <br />Q) CROSS STREET / �/ %) � -e �\ 1,� r -r) • APPN U (2 /-y ,?3GG I PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME t�� c, Y\ V `'��/7r�JN[y�` %PPH.O,NE _ '---1 _ 1 � cco <br />OWNER ADDRESS C� C% IC T� F� Q�••� CITY/STATE/ZIP QxA 1A-) (­ q q5%('-3 3 <br />CONTRACTOR VV\, Ie 7 r � 1\ �%�TN `l (PHONE �a 1 — a j'79 <br />CONTRACTOR ADDRESS p, O �i U %` A X CITY/STATE/ZIP G --:i 41 C A lfi� <br />PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE//ZIP <br />LICENSE XC -57 )C C-61 D-09 Other NUMBER EXPIRATION <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />Township _ Range <br />Section <br />INTENDED USE Domestic/Private )Clrrigabon/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: er System Nam Contact Nam or Phone Number <br />TYPE OF WORK XNew Well Replacement Well Well Alteration/Modification I Other <br />Monitoring Well(s) # of wells Soil Bodng(s) u of tx,rirgs Geotechnical # of bo ngs <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 qQ( `ft Excavation1- in diameter n Open Bottom k Gravel Pack/Gravel Size If'q — in diameter <br />- Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter g in Thickness/Gauge/ASTM SchedC 1' 12610 Steel Plastic Stainless Steel Other <br />Grout Seal Depthft Neat Cement (94 lb bag/5-10 gal wafer) XSand Cement �O •3 sack man gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method jLPumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By X Driller Pump Contractor Other <br />Concrete Pedestal 'Dimensions: Width ? It Length A It Thick in Christy Box r Stove Pipe <br />PUMP Submersible Turbine Other HP_2.cL7— Pump Set 3Ck: ft Standing Water Level t q G 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 2-,444 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />INSPPECTIOvNS - PLEASE CALL (209) 953-7697 <br />SIGNED' R •/ / W `� �'*K/'\ TITLE ) 1 ( e- ?r` Is. DATE –1 17(I 15 <br />to <br />D <br />At <br />m <br />N <br />(614 <br />Area (J-7/ '7 1 Employee ID# - <br />7 SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />PE SC Received <br />Codes Info B <br />In <br />I <br />LY <br />Uj <br />r7 <br />G`J <br />4(. <br />W7 <br />�.. U1o <br />�l <br />?�a DEPARTMENT USE ONLY <br />SLU <br />o c:ation Accepte J Datet <br />�W <br />rout Inspection B < Date <br />512 0<0 14,t'14 <br />O 7 <br />Y• <br />Wmp Inspection By <br />Date7 <br />moilring Inspection By <br />Date <br />CHIME S <br />to <br />D <br />At <br />m <br />N <br />(614 <br />Area (J-7/ '7 1 Employee ID# - <br />7 SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />PE SC Received <br />Codes Info B <br />Check#/ <br />Cash <br />AmountDate <br />Remitted <br />Permit' Invoice# WellID# <br />Seryice Re uest# <br />4(. <br />�� , <br />—<XW 303 <br />.- <br />512 0<0 14,t'14 <br />- <br />wgaonq <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />