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WELLIPUR/11P FERN V <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 9868 East Hazelton Avenue - STOCKTION CA 95205-6232 - (209) 468-3420 <br />NoN-RuUNDABLE PERMl T <br />CALL 209 <br />953-7697 FOR INSPECTIONS <br />ILGll�IN'lRES i YEAR FROM UA E IISSUED <br />1 ��0 f �� <br />Date <br />IZA CITY/ZIP <br />�T�C�-0h CAS q5�15 <br />JOf3,ADDRESS k <br />_� <br />n <br />� <br />.n /� <br />CROSSSTREET �TtC' J A L' � <br />=-!'4`" j i J`0 SO"1 C� PARCEL SIZE Lb_trt6AND USEA`P,PLICATIOyN# <br />i 1 1 <br />1 1 <br />OWNER HAMS i1 i'm Raii <br />3���OIL <br />PHONLE <br />OWNER.".DDRESS �� � 1c Gtt`kV <br />,?- <br />CITY/STATE/ZIP <br />!S 4OC G <br />CONTRACTOR"r P I, lC <br />�(]I I 1 <br />i <br />PHONE � ZZ��I � � �J3 <br />-� <br />(!!ZIA <br />< L <br />�/�ZIP tol <br />CONTRACTORADDRESS II U C r <br />) �t-i 1 <br />CII (/STATG <br />/r �6(/�e-S l_�1 ` J J. J <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE W-57 El C-61 ❑ D-09 <br />❑ Other <br />NUMBER <br />t/ �c <br />3v —1q <br />ExPIRATION DATE �l -36 <br />GEOGRAPHICAL INFORMATION: Coordinates )( Y Township Range Section <br />INTENDED USE ❑ Domestic/Private rrigation/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 `KNew Well ❑ Replacement Well 0 Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical tAof borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pumo ReDlacement ❑ Pump Reoair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ud Rotary ❑Air Rotary ❑Auger ❑ <br />Wble Tool ❑ Push Point ❑ Other <br />l <br />Proposed Weil Depth '356 ft Excavation Iq in diameter ❑ Open Bottom Gravel PacldGravel Size 6_ in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth Ift <br />Well Casing Diameter $ in Thickness/Gauge/ASTM Sched 26 0 ❑ Steel XPlastic ❑ Stainless Steel ❑ Other <br />GP0LIt Seal Depth c�7 ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br />>(Bentonite (20% solids) ❑ Other <br />Grout Placement Methodd-YPumued ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller KPump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width fl: Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />1'uiviP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft `Standing Water Level ft <br />I HEREBY CERTIFY TH!`,T 1 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 .1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS �^ <br />SIGNED _t�e1 TITLE `�'� �/- DATE_/� <br />�L L�4PA•\PJF10FN IT USir E OIdLif �QWAe�, <br />Application Accepted fay r Date <br />Grout Inspection By C N7 rV1 Date <br />Purnp Inspection By 0 Date <br />Area Employee IW <br />PECIAL Well Permit <br />WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS ,�y I j)QL.l J, <br />en <br />m <br />0- <br />PE <br />Codes <br />SC <br />Irmo <br />Received <br />BA <br />Check#/ <br />as <br />Amount <br />emitted <br />Date <br />Permit/ <br />Service Request <br />Invoice <br />Well ID# <br />3 <br />$317 <br />-2�i <br />3���OIL <br />EHD 43-06 WELL /PUMP PERMIT <br />6/04/08 <br />