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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE <br />CALL (209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />iP�ERR,/MIT <br />JOB ADDRESS Qc`, `-^ r) 1 <br />\_ f <br />� w j -�? C' CITYIZIP L <br />t h A e n t� `�' 3G <br />Jl <br />CROSS STREET NJ 5J � e 11 �\ 11 <br />7 7 <br />RD AP U �✓ / 3C6 I PARCEL SIZE <br />LAND USE APPLICATION # <br />OWNER NAME � / Cq Y\\ �/ <br />our1'e `(�� <br />/ <br />_L-_7 ­ I �r�rY_1 <br />OWNERADDRESS �1`' O <br />IC S� F�y�V CITY/STATEIZIP <br />�-PHHO�NE <br />(3r�1 I (-'A q k -,S <br />CONTRACTOR] <br />r�/1 1\%�� \ E� <br />��L� � / CI <br />CONTRACTOR ADDRESS C1 1 <br />U Y, 4 CITYISTATE/ZIP <br />PHONE <br />( <br />v" I � CA !�j j <br />SUBCONTRACTOR <br />Date <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITYISTATE/ZIP <br />Date <br />� <br />CAMERTS <br />LICENSE C-57 . C-61 <br />D-09 Other NUMBER <br />EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />INTENDED USE Domestic./Private >Qrngation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Weter bystern eme C.nt.d N.mo or P ne NUT,l <br />TYPE OF WORK )<New Well Replacement Well <br />Monitoring Well(s) # of wells <br />Out -Of -Service Well <br />Well Alteration/Modification ❑ Other <br />SoilBoring(s) #ofbodngs Geotechnical <br />Out -Of -Service Well Renewal n Cross -Connection Repair <br /># of bonngs <br />Drilling Method )< Mud Rotary n Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth '1,4( ; ft Excavation JA in diameter n Open Bottom x Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter g in Thickness/Gauge/ASTM SchedC� 966 ❑ Steel Plastic Stainless Steel Other <br />Grout Seal Depth1�c ft Neat Cement (94 Ib bag/5-10 gal water) X Sand Cement C 7 sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement MethodnPumped iJ Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By X Driller u Pump Contractor Other <br />Concrete Pedestal nDlmensions: Width ft Length ; It Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine nOther HPC Pump Set 7; ft Standing Water Level <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 244 HOUR ADVANCE NOTICE REQUIRED FO`R1 INSPECTIOpNSC- PLEASE CALL (209)) 953-76197 <br />SIGNED: 9 R // GL��'+tCi'� TITLE V r C e- V ftf J DATE <br />JA IJA I <br />N <br />m <br />D <br />X <br />m <br />N <br />Area !Tt/ ! i Employee ID# t e� Lt7� <br />1�SPEC`IALL Well Permit <br />I WAIVER Received <br />Constructed Well Depth <br />PE SC Received <br />Codes Info B <br />Check#/ <br />Cash <br />Amount Date Permit/Invoice # <br />Remitted Service Re uest# <br />Well ID# <br />L.1 <br />�7� <br />I <br />Y, 001W> <br />�� r <br />'W <br />ZU;d DEPARTMENT USE ONLY <br />Q �LLI <br />gnpation Accepte Date Y r <br />Inspection B Date <br />Q) <br />w <br />O =rout L ` <br />Y+ <br />a. M <br />Y• <br />v <br />W mp Inspection By <br />Date <br />Boil ring Inspection By <br />Date <br />CAMERTS <br />JA IJA I <br />N <br />m <br />D <br />X <br />m <br />N <br />Area !Tt/ ! i Employee ID# t e� Lt7� <br />1�SPEC`IALL Well Permit <br />I WAIVER Received <br />Constructed Well Depth <br />PE SC Received <br />Codes Info B <br />Check#/ <br />Cash <br />Amount Date Permit/Invoice # <br />Remitted Service Re uest# <br />Well ID# <br />L.1 <br />�7� <br />'`{( Ila I� 3183 <br />�� r <br />(4,tM,4 <br />JQ O U <br />EHD 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />