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Nh-17S 1 lt� <br />WELL/PUMP PERMIT <br />SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT % CALL (ZU{f�9I) 953-7697 FOR INSPECTIONS tAl'IK}�t' 'I TEAR FROM DATE 155UED <br />JOB ADDRESS v 1- � S v% e � S L -"y �q P L- [ CITY/ZIP 5 S� I ` � 9 l 4O <br />CROSS STREET ojam ! rf k� APN 09 7 !t/:>1 Li PARCEL SIZE O-ZL� L�4ND USE APPLICATION # <br />OWNER NAME <br />OWNER ADDRESS <br />PHONE <br />CONTRACTOR , Ne, �p O ,L Pf��1� /� PHO,NE 2L7�1- 3LI - 3 Za/ <br />Z <br />CONTRACTOR ADDRESS I O � � � e, rT d N '�(G —/ CITY/STATE/ZIP Lod, �;/1/�( 9-� O <br />SUBCONTRACTOR NW/4 PHONE IY14 <br />SUBCONTRACTOR ADDRESS A71f- <br />LICENSE XC -57 C-61 D-09 Other <br />CITYISTATE/ZIP ti,14 <br />NUMBER oQ EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X 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 Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings a4eotechnical 2 # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair A//�� V■� <br />New PumD PumD Replacement Pump Repair Raise Well Casinq P� 1 ! A&:r ,, <br />WELL CONSTRUCTION IT Cie, <br />Drilling Method "ud Rotary Air Rotary )Auger Cable Tool Push Point Other C 6 <br />Proposed Well Depth 16I' 3C ft Excavation 6 in diameter Open Bottom Gravel Pack/Gravel S' N % o yR ameter <br />Conductor Casing in diameter / Conductor Casing Depth ft S U CU <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel SAW <br />�W/N r^n,,,._ <br />ly <br />Grout Seal Depth ft XNeat Cement (94 Ib bag/5-10 gal water) Sand Cement NEALT►-fRrp�i�!+(Lgal water <br />Bentonite (20% solids) Other ARTMENT <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 It 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 />DEPARTMENT USE <br />N L Y <br />fin/ <br />Application Accepted B Date. Area Employee ID# V V V <br />Grout Inspection By / t� Date SPE IAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />Iia <br />PE Sc <br />Codes Info <br />Received <br />By <br />Chec <br />--aa—STI1 <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />7 V1 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />