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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)4613-3420 <br /> NEON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 'I' YEAR FROM BATE ISSUED <br /> cp <br /> Job ADDRESS r��L�1 �.�{�./% ,�,f.7+Y F_ CITYIZIP 6 5�ce �y"T/[/ �_� —`-' "' <br /> CROSS STREET [ "^ lr_APN_ U \ PARCEL SIZE ,/4i Nf}USE APPLICATION/IFS m <br /> OWNER NAME �Gx. F PHO�-NE�/ <br /> OWNER ADDRESS s� l AV'F_ CfTY15TATE/7IP dc(3 20 <br /> CONTRACTOR OQL -AV PHONE <br /> GONTRACTORADDRE55t>I(/(/ S - f CITYISTA"rC1Z[P-- ./-0Q <br /> e—,, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE 611557 ❑ C-61 ❑ D-09 ❑ Other NUMBER (EXPIRATION DATE <br /> GEOGRAPHICAL 114FORMATION: Coordinates X Y Township Range Section <br /> INTENDED Us>_ ❑ Domestic/Private rrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> C Public Water System <br /> if different from Ormer: Water System Name conLact Name or Phone Number <br /> TYPE OF WORK &<ew Well D Replacement Well ❑ Well Alteration/Modificalion ❑ Other <br /> u Monitoring Well(s) #of wells ❑ Sail Boring(s) _ #of borings ❑ Geotechnical n of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump i7 Pump Replacement ❑ Pum2 Re air ❑ Raise Well Casing <br /> WELL CONSTRUCTION/ <br /> Drilling Method b ud Rotary ❑Air Rotary ❑ Auger Cable Tool ❑ Push Point ❑ Other <br /> rr/ <br /> Proposed Well Depth�ft Excavation in diameter ❑ Open Battom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter—9- in Thickness/Gauge/ASTM Sched := ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seai Dep ft `u Neat Cement(94 ib bag/5-10 gal water) C Sand Cement sack mix17 gal water <br /> entonite(20%solids) ❑ Other <br /> Grout Placement Meth©d &15umped ❑ Free Fall ❑ Other ❑ Retardant I Accelerator(name) <br /> 92ESTAL Installed By ❑ Driller Vrump Contractor ❑ Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP u 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 /> t3 , MI UM 24 HOUR ADVANCE NOTICE R UIREQ_EQR INSPECTIONS <br /> SIVNI=D TITLE DATE <br /> V <br /> NT <br /> V�p <br /> 2013 <br /> "N DUIV <br /> Cr t rAL riv <br /> -- rAR1=7YT <br /> -71 EHE <br /> DEPARTMENT USE ONLY <br /> Application Accepted B Date Area C1 Employee f D# Q Li i�S <br /> Grout Inspection By Date ` / E L Wel) Permit <br /> Pump Inspection By Date 1z WAIVER Received <br /> Soil Boring Iny4ction By Date Constructed Well Depth ft <br /> COMMENTS H� c c LC Sa Cho <br /> PE Sc Received Choogw Amount Date Permit/ Invoice# well lD# <br /> Codes I Info By ash Remitted Service Reguest# <br /> END 43-06 WELL/PUMP PERMIT <br /> SI WOLI <br />