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�2 <br />` WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />N(JN-KEFUNDABLEE VEERRMMIT /%�,G/A,LLLLy(ZUU) VOS-IbUt FOUR INSPECTIONS LAVIKtJ I YEAR FROM UA7 IE 155UEL) <br />JOB ADDRESS /`z i-j[{� f'r] / �G o6t 7 1"I�� CITY/ZIP <br />CROSS STREET` APN Z�J I / G ti PARCEL SIZE LAND USE 9APnPLILICATION # <br />OWNER NAME �V`�> O 3wie, k�/tA\ ,vt3 !% PHONE (Lv-I ZLoI-�Lrj <br />OWNER ADDRESS_'�� 16[ � JCi • ! �O CITY/STATE/ZIP 7�-ac�( c CA �t531-1 <br />CONTRACTOR `vL� Epi �QA� Ci k c.&'CScI� PHONE (Z � 3(0 -3�C <br />CONTRACTOR ADDRESS C1(,2- W(WSt�' CO W ck,l' <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ✓C-57 C-61 D-09 Other <br />CITY/STATE/ZIP (_L)Ck\ , LP� C�5 Z LLk0 <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER (0(6C1(\;0L'I EXPIRATIONDATE <br />GEOGRAPHICAL INFORMATION: Coordinates �_T-1t�0l[) Y-���(.�LA(-)Z 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 Fhone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells X5011 Boring # of borings s) 1 Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Hump rump Replacement Hump Kepair Kalse vveu c;asing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary /Auger Cable Tool Push Point Other <br />Proposed Well Depth L((; ' ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 1 Steel C' Plastic Stainless Steel Other <br />Grout Seal Depth ft `Neat Ceme t (94 Ib bag/5-10 al wat r) sack mix/7 gal water neM <br />Bentonite (20% solids) /NOiger - C! Sa ement <br />Grout Placement Method Pumped Free Fall Other Retardant / 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 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 />MINIMIj�II 2�4 HIOUR AM NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED �// TITLE&4e,,NMiLc/ bg!4t 41141I�J�✓ DATE ✓J <br />� v <br />T <br />D <br />v <br />v <br />M <br />m <br />Ul <br />EP RTMENT U E O LY � <br />Application Accepted By Date �— Area Employee ID <br />4/49A <br />%.' <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC <br />Info <br />ReceivedCh <br />B <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />