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WELL/PUMP PERMIT <br /> SAN JOAOUIN 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 Ln <br /> JOB ADDRESS (o2-� t hno T CITY/ZIP <br /> v <br /> CROSS STREETS r //� ►�W _APN 252-0 ID-� PARCEL SIZE // LAND USE APPLICATION# y <br /> OWNER NAME �)U�n U!ro'w' Co raN-1w PHONE D - IO3q-- N <br /> OWNER ADDRESS 2-:4 51 el I Gate- <br /> 1 e/ l d.► 4:alr _ CITY/STATE/ZIP �(� //� Q� <br /> CONTRACTOR �P ry)I S �� �h/lJ� ��11I�� PHONE //21J1��}/1�+_ I"�/ <br /> CONTRACTOR ADDRESS I 1 3O Ll.L.rL.f kd CITY/STATE/ZIP- 11 C4 I 9�S5(/ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 11 C-61 I D-09 11 Other NUMBER 2-c-7D S 1 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private E Irrigation/Agricultural U Industrial J Water Quality Monitoring U Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name —fact Name or Phone Number <br /> TYPE OF WORK XNew Well I1 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) a of borings U Geotechnical #of borings <br /> 0 Out-Of-Service Well U Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> i New Pump F' Pump Replacement ❑ Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,�<Mud Rotary F] Air Rotary C Auger 0 Cable Tool U Push Point 0 Other <br /> Proposed Well Depth ZSD ft Excavation 1— in diameter -] Open Bottom )C Gravel Pack/Gravel Sizein diameter <br /> Ll Conductor Casing in diameter / Conductor Casing Depth ft 4'-' <br /> Well Casing Diameter-K in Thickness/Gauge/ASTM Sched SU 9-1, `1 Steel Plastic C Stainless Steel 0 Other <br /> Grout Seal Depth_IM' _ft Il Neat Cement(94 lb bag/5-10 gal water) 0 Sand Cement sack mix(7 gal water <br /> )4-Bentonite(20%solids) I 1 Other <br /> Grout Placement Method umped :_l Free Fall ❑ Other U Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller IVILjmp Contractor ❑ Other <br /> Concrete Pedestal F.Dimensions:Width ft Length ft Thick in L7 Christy Box 0 Stove Pipe <br /> PUMP F Submersible I! Turbine r 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 COMPENSATION LAWS. <br /> MINIMUM ?4 HOUR ADVANCE NOTICE ED FOR <br /> INSPECTIONS-PLEASE CALL(209) 953-7697 <br /> SIGNED -b-/J RE IRS3 TITLE �l �• DATE ` —17 <br /> 14 '117 1 <br /> Y <br /> IV <br /> E A cOF CO <br /> I <br /> L <br /> L•,n • 1 i T A■ ` N' T S G C N L V <br /> Application Accepted By Date �� � Area Employee ID#-IAe O uws <br /> Grout Inspection By Date 8 'Y 0 SPECIAL Well Permit �I <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Conswiucted Well.D�Pth US _ft <br /> CO ME TS d z (r <br /> PE SC Received he Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> $� 93s .� `��� 7 `��.66 77 V W�003�53q <br /> I <br /> EHD 43-06 <br /> 4/30/12 WELL/PUMP PERMIT <br />