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u1:3& <br />a��E�VI <br />AQV1N <br />SAN�� INOM� <br />He�TH DEN <br />WELL/PUMP PERMIT <br />SAN JOAQUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 <br />(209)468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />2DDREss �-I E. H w L n d, e o ci 5:�3(, <br />Joe ADDRESS CITY/LP I <br />CROSS STREET Irl <br />OWNER NAME <br />1'� <br />APN ��,A L� Q>ARCEL SIZE �t'/ /�' ND USE APPLICATION # �'J <br />_ - /'I [7CL � (PHONE ,1T" ' IC'K <br />OWNER ADDRESS <br />O v/ \ �I-Z�7� <br />? V C� <br />q3LF', <br />CITY/STATE%dP -Cl 7 �fq.� <br />CONTRACTOR �a <br />GI <br />1 <br />IQI rl �l_ <br />/��1-1 �r]"I <br />PHONE 3 VCS I _ �.'"` 7.y 7 <br />CONTRACTOR ADDRESS <br />P. C, 13 C> <br />X 1 T <br />/1 <br />Cm/STATEZP C- 10 � I CA C 17 4% <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />EHD 43-08 <br />4130112 <br />CITY/STAUTEILP <br />LICENSE C-57 <br />C-61 _ D-09 <br />_Other <br />NUM13ER ICI 3 u ExPIRAnoN DATE _ <br />GEOGRAPHICALINFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE _7 Domestic/Private `& Irrigation/Agricultural 7 Industrial = Water Quality Monitoring - Soil Sampfing/Characterizabon <br />Public Water System <br />If dSerem from OwnerWater system Nam corNacl Nam of FRone Numbm <br />TYPE OF WORK New Well - Replacement Well - Well AReration/Modiftcation --Other <br />Monitoring Well(s) # of wells - Soil Boring(s) • of borings Geotechnical >x of borings <br />Out -Of -Service Well - Out -Of -Service Well Renewal - Cross -Connection Repair <br />"A KI— P„mn - Pmmn Rnnlarnmant - Pumn Repair - Raise Well Casino <br />Drilling Method Mud Rotary Air Rotary - Auger - CaNe Tool - Push Point Other I /d <br />Proposed Well Depth S( -U ft Excavation 1_ in diameter - Open Bottom 'X Gravel PaddGravel Sizer diameter <br />❑ <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 21 in Thickness/Gauge/ASTM Sched C 19LA l _ Steel )T Plastic = Stainless Steel - Other <br />Grout Seal Depth GO ft - Neat Cement (94 Ib bag/5-10 gal water) Sand Cement 1C sack mix/7 gal water <br />-i Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other _ Retardant / Accelerator (name) <br />PEDESTAL Installed By� Driller Pump Contractors Other <br />Concrete Pedestal -Dimensions: Width _J ft LengM ftThick � in Christy Box : Stove Pipe <br />uMPSubmersible - 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. 1 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 24 HOUR ADVANCE NOTICE REQUIRED FO`Rl INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED / �( / 6"z'Zy-r.' TITLEy c C. }7 r C� i C� C' F1 1r DATE 1 I 7 <br />DEPARTMENT USE ONLY <br />Application Accepted Date Al <br />Grout Ins Wy' Data ` <br />Pump Inspection By Datel <br />Soil Boring Inspection By Date <br />COMMENTS (J J lk-e)) CA= l i J L LL e'a 1 1 I iy <br />W <br />S <br />b. <br />Area "" �� Employee ID# <br />D SPECIAL Well Permit <br />-1 WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC Received <br />Info BY <br />Check#/ <br />Cash <br />Amount Data Permit/ <br />Remitted Service R uest # <br />Invoice # Well ID# <br />q3LF', <br />k U <br />(o tv)tpq - <br />as i <br />EHD 43-08 <br />4130112 <br />/ //-� <br />I/(,•• J <br />WELL/PUMP PERMIT <br />