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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> SN GORNEJtoF� A NDN• RfyNoldQS R 914 CAm ' LaDi a SZ�� D <br /> A/J Cr // �L 0 <br /> CROSS STREET /71 #46 iw- AP D 5'$10 O C PARCEL SIZE ,2-l�6 USEAPPLICATION# m <br /> OWNER NAME <br /> . � f� I�Rrw'T1 PHONE I ,jqj ����� N y� <br /> �J C D /��.y /� Q� ff y <br /> OWNER ADDRESS?'-I �•�•I rr1�I�l ^�•./�"u �- CITY/STATE/ZIPM�•�Q •(��0 <br /> CONTRACTOR W A'^�I��/►'!l{��e�A'�• ; ^�.s / ��PHH.NNE(d)/6-.T7 7-—j /34-j <br /> CONTRACTOR ADDRESS JV 7w XAZ& I?GI�At#' CITY/STATEIZIP/A/W + Q—qt <br /> [/A <br /> SUBCONTRACTOR DR+I c..PPH�HOO�N��E//�I.7 `Q`�oO <br /> SUBCONTRACTOR ADDRESS�{/ �V1 CIT�jY/STQATE/ZIP S(01AKVAliX� 15�71s— <br /> LICENSE C-57 - C-61 D-09 Other NUMBER pp` -1 A EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X3,1./00-3 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 one Numoer <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings xGeotechnical JA ff of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Rgj& Ra' Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rola Air Rotary xAuger Cable ool u MIT <br /> her <br /> IR <br /> Proposed Well Depth ft Excavation in diameter Open Bottom rave Pacc Grave ize n diameter <br /> Conductor Casing in diameter / ConductorReTirkri�f�rp� R�} �} <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ree P a ys et l <br /> Grout Seal Depth ft xNeat Cement(94 lb bag/5%iQ ' lRg ( IQ 4Lalt/I�x/7 gal water <br /> Bentonite(20%solids) Other >/ ��`���r�r�r��++�r 11 <br /> Grout Placement Method Pumped Free Fall Other } hfigInn <br /> PEDESTAL Installed By Driller i 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 /> MG U�R!ADVANCE NOTICE REQUIRED FOR IN PECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED <br /> TITLE JTAF�IiMEE�2 DATE <br /> TENT <br /> 5 2013 <br /> IN COUNTY <br /> MENTAL <br /> DEPARTMENT <br /> DEPARTMENT USE O LY `, e1 <br /> Application Accepted By Date Area �� ` Employee ID# t 5 "f f <br /> Grout Inspection By Date ❑ SPECIAL WBII Permit <br /> Pump Inspection By Date -7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS • <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> 3 ISw'a sv 3A131 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />