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r lZ. WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)46$-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 41 /5 �I Ver b Ail (J k,n,'„{[ CITY/ZIP 1� -t 1 Jf I `-f 7 `tel 1 rn <br /> n <br /> /��'r����`�� ��1 ff a <br /> CROSS STREET l —7 �Ar7 APN t t () 1j Y 9 �- PARCEL SIZE 0- LAND USE APPLICATION#1 rn <br /> OWNER NAME /T Yi h r'I f��i�r rfr f? J ( r PHONES UCf�'} <br /> OWNER ADDRESS /(�rr l G. <br /> 1C t'1I1T{� J CITYISTATEIZIP + 6,h t�+r CA 7 <br /> CONTRACTOR /iI Cr J V /T�'jer5C!? i SG'L��t �S PHONE — 3Gr M <br /> Cr{ <br /> CONTRACTOR ADDRESSy Z_ 11 d t, if1f 1 CITYISTATEIZIP ll—J' G �_`+f5 2—'bo <br /> SUB /} <br /> CONTRACTOR !"�� PHONE 'V/`l.y'I <br /> SUBCONTRACTOR ADDRESS / !' CITYISTATEIZIP �/4r <br /> LICENSE NC-57 C-61 D-09 Other NUMBER t7 flGOq EXPIRATION DATE 7 f I f U t <br /> GEOGRAPHICAL INFORMATION- Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sam plinglCharacterizafion <br /> Public Water System <br /> If different from Owner: Water ys em Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well AlterationlModification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) ft of borings Geotechnical #of borings <br /> Out-Of-Service Wel Out-Of-Service Well Renewal Cross-Connection Repair <br /> i New Pump Pump Replacement [.I Pump Repair Raise Well Casing <br /> WELL,CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary ;Auger Cable Tool Push Point Other &22� <br /> Proposed Well Depth I & ft Excavationes in diameter Open Bottom Gravel Pack/Gravel Size in i At� <br /> Conductor Casing in diameter 1 Conductor Casing Depth ftJO DUIN CO <br /> Well Casing Diameter in Thick nesslGaugeIASTM Sched Steel Plastic Stainless Steel Q3iRO � rY <br /> Grout Seal Depth ft Neat Cem—t fQA 1b bag/5- 0 gal water_) Sand Cement sack m"X#fC A dr <br /> Bentonite(20%solids) >(Other <br /> Grout Placement Method Pumped Free Fall Other Ret6rdant I Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> Pump Submersible Turbine Other HP Pump Set It 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 CO ENSATION LAWS. <br /> MINI U0A 24 HOUR=E NOTICE REQUIRED FOR INSPECTIONS - PL/EASE CAUL(209) 95`3-7697 <br /> SIGNED �� TITLE 0f64<i Z e /tlDATE ! �� <br /> J <br /> C <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date -- Area Employee ID# SSC r' <br /> Grout Inspection By Date -1 SPECIAL Well Permit <br /> Pump Inspection By Date El WAIVER Received <br /> Soil Boring Inspectio Date 'l-!�' Constructed Well Depth ft <br /> COMMENTS / s7 r/i <br /> PE SC Received C--Check#W Amount Date Permltl Invoice# Well ID# <br /> Codes Info B ash Remitted Service Re uest# <br /> .�L_k%-16 5gtoj jj�L+5 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4!30112 <br />