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WELL/PUMP PERMIT P '/ <br /> SAN JOAQUIN 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 <br /> JOB ADDRESS 1 I I^,��a lA CITYRIP— D <br /> `�V t � APN 2y I o - �GJ PARCEL SIZE / LAND USE APPLICATION# m <br /> CROSS STREET — -7 N <br /> OWNER NAME <br /> (l�L:— <br /> J ��`e� PHONE 60(x P 1 �q to <br /> �S-Cd( 1q CCS �S�ZJ <br /> OWNER ADDRESS I CITY/STATERIP i J — <br /> CONTRACTOR r 1 j n __._ PHONE <br /> CONTRACTOR ADDRESS I J �li'V`rS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE V-1-57 IC-61 D-09 11 Other NUMBER _ EXPIRATION DATE 11/t 1 <br /> GEOGRAPHICAL INFOATION: Coordinates X Y Township Range_ Section_._ <br /> INTENDED USE Domestic/Private I- Irrigation/Agricultural ❑ Industrial I Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> I Public WaterSystem <br /> It different from Owner: Wafer System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well 1 1 Replacement Well IJ Well Alteration/Modification I I Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings U Geotechnical #of borings <br /> 0 Out-Of-Service Well U Out-Of-Service Well Renewal i_I Cross-Connection Repair <br /> Fl New Pump Pump Replacement r_ Pump Repair I I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary. ❑ Air Rotary Auger _i Cable Tool rl Push Point ,J Other <br /> Proposed Well Depth L� ft Excavation in diameter _1 Open Bottom Gravel Pack/Gravel Size_in diameter <br /> J Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched ZO b J Steel �CPlastic C Stainless Steel ❑ Other <br /> Grout Seal Dep h_ ft Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> entonite(�0%solids) I Other <br /> Grout Placement Method umped ,_7 Free Fall i Other C' Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 7 Pump Contractor ❑ Other l <br /> Concrete Pedestal ;-Dimensions:Width it Length ft Thick in ❑ Christy Box f-1 Stove Pipe J <br /> PUMP I' Submersible[; Turbine 1 Other HP Pump Set ft Standing Water Level 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 PULES 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 /> MIWUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209) 953-7697 <br /> SIGNED_ �—� � TITLES/ T"1 I V� DATE <br /> 1' <br /> f� <br /> � s <br /> ti <br /> (� I <br /> 1 IB NYNiE <br /> FIN El <br /> 1� <br /> 01 Il o <br /> H L H E R M N- <br /> -T <br /> l I I I I i I I I i L <br /> 11 E P R T M E N T U 5 E 9 N L Y <br /> Application Accepted By Date -1 _ O Area Employee ID#hil" <br /> Grout Inspection By L t I Date 5 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 2 ✓_O ft <br /> COMMENTS 'bS '.__ r-V w S <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> t <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />