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N410 5Q3t <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS ) ^EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS l -/VL rY ;41_tTje?',1h 5/�, / CITY/ZIP W< I q5�V <br />CROSS STREET L_GcKe{y�' APN V -I ) —'V - 60 � PARCEL SIZE L _r('LAND USE APPLICATION ## <br />OWNER NAMEaffy PHONE I T`l n <br />AA <br />OWNER ADDRESS J CITY/STATE/ZIP �Jfj� / <br />CONTRACTOR /V�lI�1 (/%AnLkl) 1 1 e��„'�/Wrl 1 IP_HONE 64 " r (�Cb,7,,{-3 <br />Wi <br />CONTRACTOR ADDRESS 9OZ �Y1(1144- F,al ,, CITY/STATE/ZIP w�l f,"I/�"'�/ <br />SUBCONTRACTOR n✓/�I^K' PHONE <br />SUBCONTRACTOR ADDRESS/'I CITY/STATE/ZIP <br />LICENSE <br />?(C-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring ,)(Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings k -Geotechnical _# of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth lf; jj ft EXcavation _ in diameter Open Bottom Gravel Pack/Gravel Siz in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft r <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel <br />Grout Seal Depth ft Neat Cemre�nt (94 Ib baLg/15-10 gal water) Sand Cement_ sack mr water <br />Bentonite (20% solids) Other IUi (n l 'I I C S A► R - ^ -- <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) CA&, ' 'j ZU <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in <br />Submersible Turbine Other HP <br />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 ACT[VkOTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPEN4TM LAWS. <br />MINIMU OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) �9y5�73-7/69[7 <br />SIGNED TITLE SPr1,a� S�(iI"� �I')Q Y1Per DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS I / / <_ <br />PAY7MENT tjSE ONLY <br />tew��71'v <br />Date <br />Date <br />Area Employee ID#" <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Amount <br />ash Remitted <br />Date <br />Permit/ <br />Request # <br />Invoice # <br />Well ID# <br />lService <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />