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Int 1�►tu-- <br /> WELL/PUMP PERMIT <br /> fix" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDAB E PERMIT CALL 209 953-7697 FOR INSPECTIONS XPIRES 1 YEAR FROM DATE ISSUED <br /> r ./�/} �/ 4)� trn Cg / <br /> JOB ADDRESS ✓ ►I'e I � o •t V' CRY/LP • S LMD <br /> CROSS STREET I OM1 UU APN Sob 0 PARC LSIZE}�•�J9 LAN OYWS PLICATION# +� y <br /> OWNER NAME[ Gar in c Cr Y GIAq ONj�,'� I {/� 1 <br /> $W 11 GRESS G 5 1I 1 ey-t v 1f U <br /> OWNER ADDRESS � /� I/� CITY/STATEIZIP 7 C( <br /> CONTRACTOR T Lc` 6 c, ! L.r►� 4 No!E V _1 A (jab N <br /> CONTRACTOR ADORES) 5 _ CITY/STATEIZIP �� /,�/I �� 7 <br /> SUBCONTRACTOR N PHON <br /> IV jf� ZmZ, <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 5 ® O <br /> EXPIRATION DATE Ivo <br /> LICENSE C-57 C61 D-09 Other NUMB n <br /> —4 <br /> GEOGRAPHICAL INF n15N: Coordinates X Y Township_ Range Section_ .� <br /> INTENDED USE V Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> b t� <br /> Public Water System 1�9 <br /> 11 different from Owner Water sySteM Name Qontact Name or Phone Number � <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other �I <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Servic?�IfiII Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump V Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION C <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bao-10 gal water) Sand Cement sack mix/7 gal water <br /> / Bentonite(20%solids) Other S <br /> WI Grout Placement Method Pumped Free Fail Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller I Pump Contractor Other •� <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in I Christy Box Stove Pipe 1_A <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level 129 it <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 V - <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP NSATION LAWS. <br /> MINIM 4 HO ADVANCE NOTICE REQUIRED FO , <br /> INSPECTIONS--PLEASE CALL(209)9�3 97 / <br /> SIGNED TITLE J�• "'�-•/ L�L DATE b <br /> A <br /> fj <br /> RFCF�T <br /> D <br /> CO <br /> �E.MFti.T U,y� <br /> �Tlt <br /> D15PARTMENT USE ONLY <br /> Application Accepted By Date 1" Area Employee ID# <br /> Grout Inspection By Date _. SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Frac Amount Permit/Codes Info B as Remitted Date Service Request# Invoice# well ID# <br /> 4381 066 17 a6 3 <br />