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i/ jjo >r <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />-Uti W4 "Y <br />Z W Ln <br />0 <br />W> y <br />�U <br />aW <br />M <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS ��� " ) "r�"�/ '^ 7 CITYIZIP i"t'�1 en 9 5 2�C, <br />CROSS STREET !V • sV).e I I'e- q QV. '�AAPNN O C-7 }G C 1 PARCEL SIZE LAND USE APPLICATION III— <br />OWNER <br />OWNER NAME �S{�()V rXrA � G ` ip1 1. ` J PHONE S lC / — 1-7 OG <br />OWNER ADDRESS 1 rJTTIJ� O R R f, o. Cm/STATE/ZIP G� 1,- 2I /'CUA cj51; 7) 5 <br />CONTRACTOR M '� c 1 I I' 1 PHONE 714/ 1 -� 7/ I <br />CONTRACTOR ADDRESS ' C' CITY/STATE/ZIP Gn I+ c A 9 9 G-5 .�)- <br />ADDRESS <br />D-09 1. Other. <br />PHONE <br />CITY/STATE/ZIP �] <br />NUMBER �iq 3S3 EXPIRATION DATE / _ 2 ✓ I _ IG <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE - Domestic/Private j rrigation/Agricultural � Industrial ❑ Water Quality Monitoring I_ Soil Sampling/Characterization <br />I i Public Water System <br />If different from Owner: Water System Name Contact Name­o­rPFc­n5­ITu­mI5Fr- <br />TYPE OF WORK (New Well _I Replacement Well C Well Alteration/Modification IJ Other <br />I Monitoring Wells) # of wells I_ Soil Boring(s) # of borings r Geotechnical # of borings <br />I i Out -Of -Service Well F Out -Of -Service Well Renewal n Cross -Connection Repair <br />--New Pumo -I PumD Replacement I Pumo Repair 11 Raise Well Casino <br />Drilling Method KMud Rotary -1 Air Rotary r Auger Cable Tool F Push Point n Other <br />Proposed Well Depth 440 ft Excavation 1, in diameter I Open Bottom )( Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter R in Thickness/Gauge/ASTM Sched1� I Steel )( Plastic � Stainless Steel Other <br />Grout Seal Depth q0 ft -1 Neat Cement (94 /b bag/5-10 gal water) (Sand Cement 1 L' sack mix/7 gal water <br />Bentonite (20% solids) a Other <br />Grout Placement Method Xs Pumped I Free Fall !J Other IJ Retardant / Accelerator (name) <br />PEDESTAL Installed By Xpriller a Pump Contractor I Other <br />}Q Concrete Pedestal 1 IDimensions: Width ft Length ft Thick - in I Christy Box 1 Stove Pipe <br />PUMP ASubmersible- Turbine I Other_ HP Pump Set CU 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) <br />SIGNED /"mac ar ul" TITLE�� ' cc I?r e DATE <br />DEPARTMENT USE ONLY <br />i43 —4E50- /' of Z -r f <br />,/Cppllica��+QJ��j�cepte ate <br />O Grout7nspection <br />Pump Inspection By <br />- Date <br />Date 4 W1;; <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />m <br />D <br />v <br />m <br />N <br />Area i% Employee ID#'� <br />SPECIAL ell Permit <br />3 WAIVER Received <br />Constructed Well Depth <br />PE SC <br />Codes Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Pem1iU <br />Service Re uest# <br />Invoice # Well ID# <br />4 ( `°�z�flsl <br />20013190 <br />--o <br />K� 1 <br />3,f'$_1 <br />a. <br />0o <br />W 00 1 <br />EH D 43-06 WELL/PUMP PERMIT <br />4/30/12 <br />JgJ6 <br />lql� <br />>7� <br />