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1ti! <br />uA7 % /t : WELL/PUMP PERMIT <br />• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 488-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB aA � � �e���'�-4— � `'i� W) r� � , I CrTYmP <br />) C-1 5 �17 <br />CROSS STREET Irl S I I� RT7 APN' K UJ PARCEL SIZE (� A USE APPLICATION # ''] �^ ('� <br />OWNER NAME (J/ \ C� %i ('(.(-PHONEl J }� • /_ 'fry C K <br />OWNER ADDRESS `7 V c' 1 (���,� D' CITY/STATE/DP ' G' T , /� <br />CONTRACTOR \d �`'I 1 1 e y I_ J f I 1 1Q I '"("� �� PHONE 3 rL� 1 7 ( 7 / 9 <br />CONTRACTOR ADDRESS C' �� C' X 1 cX CITYISTATE21P G CO V CA 615 4", S �� <br />SUBCONTRACTOR PNONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/LP <br />LICENSE C-57 C-61 _ D-09 _ Other NUMBER' <br />ExPIRATION DATE <br />GEOGRAPMCAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE Domestk/Private 'y, Irrigation/Agricultural _ Industrial -- Water Quality Monitoring - Soil Sampling/Characterization <br />Public Water System <br />If different from Owner werter system Rem eme or Mon. <br />TYPE OF WORK �,Nevv Well = Replacement Wel = Well Alteration/Modification = Other <br />- Monitoring Wells) # of wells - Soil Boring(s) III of borings Geotechnical #of borings <br />- Out -Of -Service Well - Out -Of -Service Well Renewal - Cross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary Auger - Cable Tod - Push Point -- Other I id <br />Proposed Well Depth 5(-,C) L _R Excavation 1A in diameter - Open Bottom Gravel PacWGravel Size diameter <br />G Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad .Ll' = Steel 9 Plastic - Stainless Steel _ Other <br />Grout Seal Depth GO fl - Neat Cement (94 /b beg6-10 gal water) Sand Cement IC j sack mfxl7 gal water <br />i Bentonite (20% solids) Other <br />Grout Placement Method X Pumped _ Free Fall _ Other _ Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete edestal -Dimensions: Width -7 it Len gtil ft Thidr in 'Christy Box Stove Pipe <br />PUMP ulxnerside- Turbine Other HP x Pump Setft 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 <br />to <br />a <br />m <br />v°q v U16 <br />�q�V N <br />Ty q�p ENVt <br />V c r h rt r m c rt r vac . c r w\ V <br />Application Accepted B 1 ,-Date (Z Zc� Area Employee IO#� <br />Grout Ins n - t - Date 7 SPECIAL 611 Pefinit <br />Pump Inspection By Date e r 1 -1 WAIVER Received <br />Soil Boring Inspection By pate 7 t Constructed Well Depth ft <br />COMMENTS r%'� -, =-r r^ C� A."C <br />PE <br />Codes <br />SC Racelved <br />Into <br />Check## <br />Cash <br />Amount Date <br />Remitted <br />Permit/ <br />Service Request # <br />Invoice # <br />T � <br />i-v� <br />61' <br />ON <br />° <br />1 <br />W <br />-:-; <br />EHD43-M/ WELL HUMP PERM <br />n <br />q4 <br />