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.s <br />3 <br />y WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT CALL 209 953-7/6/97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS �` �� N 111\��( SrtC�e+nt� �C� CITY/ZIP <br />CROSS STREET t N�S �-A \ APN 1L p (� `{_ PARCEL SIZE OAL(7- LAND USE APPLICATION # <br />OWNER NAME// " �(r?, t��i7 FN, � PHONE <br />4 <br />OWNER ADDRESS -. ��-y(St2-APa CITY/STATE/ZIP <br />CONTRACTOR NQ;k\ �� Pmc�Y� �n �� ctClae s PHONE (7-'0a) <br />CONTRACTOR ADDRESS 1 O% - ��a\1 �[�C11 l (\�CXV1 CITY/STATE/ZIP t-.6C!(l <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP c <br />LICENSE q/C-57 C-61 D-09 Other NUMBER &0(CQN-Y % EXPIRATION DATE J <br />GEOGRAPHICAL INFORMATION: Coordinates X _2D%> Y 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 um er <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring # of borings s) Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <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'�-ADft Excavation CO in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thicknes /Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other l 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 />c <br />EP RTMENT _y7E ONLY <br />Application Accepted ByDate Area Employee ID#(S/t/b] <br />Grout Inspection By Date ❑ PECIAL Well Permit <br />Pump Inspection By j Date ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />m <br />m <br />D <br />v <br />M <br />m <br />m <br />W <br />PE <br />Codes <br />SC <br />Info <br />Received <br />Check#/ <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />222�fa <br />->0 `� <br />c\-'W21A <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />