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61 0� WELL/PUMP PERMIT 1"") ✓,i <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL <br />CC�A.�LyL <br />(2209 9j533--7�6/9j7 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DDAATE ISSUED <br />JOB ADDRESS � ? ( <br />x' <br />A &A2;reW/ <br />�fll/(/�� CITY/ZIP <br />i� l <br />CROSS STREET <br />APN <br />7.09 U 1 C \ 1 PARCEL SIZE 3G f LI <br />LAND USE APPLICATION # <br />OWNER NAME Mi LhcqI <br />es l',. �lJ tSQ,LI <br />PHONE (J� tnlL��- 3GtC I <br />OWNER ADDRESS L�2�5 LG1St <br />{A\1Q Y\V-Z <br />CITY/STATE/ZIP LAVQr <br />t We- c(A (Dm)c� 0 <br />CONTRACTOR Tr ct C <br />tri W l \ L ` n <br />�`I ekurs0 v) <br />PHONE 0 C!q S({ 1 - 2,-10 <br />CONTRACTOR ADDRESS (Y <br />k MOUS-C VAM W <br />GV) CITY/STATE/ZIP U <br />O(Al, O -A QS ZL'k O <br />hCj <br />SUBCONTRACTOR N <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE ✓C-57 C-61 <br />D-09 Other <br />NUMBER (0(0-l0,CL-� <br />EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X >>] -I 5s 0 Y - � Zl, . St -i 7- 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 V Soil Boring # of borings s) � Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary ✓Auger Cable Tool Push Point Other <br />Proposed Well Depth qC' 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 Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mW7 gal water <br />Bentonite (20% solids) y Other SO; 1 (' U coil o12s <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 />MINIUM 24 HOUWNCE NOTICE REQUIRED FOR I1NSPECTIONS ,-{PL/EASE CALL (209) 953-7697 <br />SIGNED TITLE �(rtl �G�! /�laMt�� DATE .+ J/ <br />T <br />m <br />D <br />0 <br />0 <br />m <br />m <br />Ch <br />Cn <br />DEPARTMENT USE ONLY <br />Application Accepted By Date l Area Employee ID#� <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By A . 4 4 Date - WAIVER Received <br />Soil Boring InspecAtion By <br />COMMENTS IA 5p <br />V <br />Constructed Well Depth <br />[ii <br />PE <br />Codes <br />SC Received <br />Info By <br />,efi—ecjkP <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />1'5V <br />z <br />? <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />