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1 <br /> WELL/PUMP PERImi i °N WdO� tiIOZ 7� 'das awll paniaaa� <br /> SAN JOAQU;,!COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE•STOCKTON CA 95205 - (209)468-3420 <br /> AEON-REFUNDABLEE_PERMIT <br /> - CALL <br /> 208 953-7697 FOR INSPECTIONS c EXPIRES 1 YEAR FROM <br /> FR (a <br /> M—DATE ISSUED <br /> JOB ADDRESS ..7�\ �ggl.1� V� 4t1 ��4 D^1� _ CITY/ZIP J ^� ( \A"�,� <br /> (� b <br /> CROSS STREET ��O` LLh W I 7[['44• AP1N• M', k"R c PARCEL SIZE J I ' LAND USE APPLICATION# y <br /> OWNER NAME S `C LAIC ✓�� av -{— PHONE <br /> OWNER ADDRESS .�� �� C� �'��n� Q• CA 95;t-2t <br /> .,+ CITY/STATE/ZIP ��'��'^Q.� <br /> CONTRACTOR �`�G%C-J:5 T�'Cofr-4 PHONE ." 1 <br /> CONTRACTOR ADDRESS N. W r�V"�l �NQ- �t >� CITY/STATE/ZIP ^ VA <br /> Cc^' <br /> SUBCONTRACTOR �fi � CFT ,P1HONE <br /> SUBCONTRACTOR ADDRESS TKk �oe I2( CITYISTATE/ZIP \1/`I I\k-N cA q ^�r,,ff T- <br /> LICENSE ><C-57 C-61 _1 D-09 Other NUMecR EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X �r�-gl�p(a Y" «� �$� Township Range Section <br /> INTENDEQ USE i 1 DOmestic/Privats ' I Irrigation/Agricultural i i Industrial I Water Quality Monitoring XSoll Sampling/Characterizatlon <br /> I Public Water System <br /> II different from Owner' a dr ys em ame an a ame or ons um °r <br /> TYPE OF WORK 1 New Well I Replacement Well I! Well Alteratlon/Modification IK Other C-2 l21 <br /> J Monitoring Well(s) #of wells - Soil Boring($) A or borings ><Geotechnical _P of bonnge <br /> Out-Of-Servlcp Well L..I Out-Of-Service Well Renewal .1 Cross-Connection Repair <br /> New Pump I Pump Replacement I I Pump Re <br /> pair i Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary I i Air Rotary 1. Auger _1 Gable Tool 911ush Point t r 1 <br /> Proposed Well Depth ��–' ft Excavation in diameter I O I 9CI �:jk Ize iameter <br /> r1 Conductor Casingin diameter / i D pw <br /> Conductor Casing Depth <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 1-1 Steel m+� 4r8t>�1frtout <br /> Grout Seal Depth F"'11 ft Neat Cement(94 1b bag/S-10 gal water) , 'I URT601111vlvow- <br /> Grout <br /> a Q dgal water <br /> Bentonite 20%solids Other �i Q r""Placement Method Pumped .1 Free Fall OtherRetard ( {� a uaill <br /> l <br /> PEDESTAL Installed(9y I l Driller I 1 Pump Contractor .I Other <br /> Concrete Pedestal L-1 DIMenslons.Width ft Length ft Thick in I.J Christy Box .! Stove Pipe <br /> PUMP i.1 Submersible_i Turbine C' Other. HP Pump SOL_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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPE>ISATIOR LAWS <br /> MINI 24 U DVAN NOTICE REQUIRED FPR INS CTIONS - PLEASE CALL (209)p95 -7697 <br /> SIGNED TITLE �� tDATE ` �2 I� <br /> DEPARTMENT USE ONLY <br /> Application Accepted „ 'L_.. - Date Area Ud `t`' Employee ID# 6t-T" iz.'LS <br /> Grout Inspection By –� Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspectlon By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Into B Cash Remitted Service/Request <br /> ■ <br /> 1 ■ <br /> EMD 4340 WELL/PUMP PERMIT IN■ <br /> 4/30/1: ■ <br /> ■ ■ <br /> TO NOdINO❑JN❑ S62T6656OZ Z6 :17T 7TBZ/ZZ/60 M 0N <br />