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WELL/PUMP PERMIT <br /> SAN JOAOUIN 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 /> - VK/ CG\�r�(\ l�-� L•" CITY/ZIP A� , _ m <br /> JOB ADDRESS `L4�'��ez, D <br /> SVY�L�1\ APN 77�Y',Q 1 M <br /> CROSS STREET j PARCEL SIZE LAND USE APPLICATION# <br /> (�U��OO<- L I / /�SJN/1`" PHONE y <br /> OWNER NAME �7 <br /> OWNER ADDRESS 1 L h !�I ,r- C }M(N , 41a- CITY/STATE/ZIP-_ � / IA !?533j.CONTRACTOR Wes� COOLS4 Cvooal <br /> F�Com- PHONE �; <br /> CONTRACTOR ADDRESS <br /> c) � T lC �3 CITY/STATE/ZIP � eu Ln, N tl'S��y <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE r►YC-57 7 C 61 ,1 D 09 [l Other NUMBER ��� EXPIRATION DATE <br /> GEOGRAPHICAL INFORM ON: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private F Irrigation/Agricultural ❑ Industrial Fi Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> [1 Public Water System <br /> If different from Owner: Water ystem Name ontact ame or Phone umber <br /> TYPE OF WORK ' New Well eplacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings C Geotechnical #of borings <br /> ❑ Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> I! New Pum D Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION/ <br /> Drilling Method L* ud Rotary r ❑ Air Rotary Cl Auger Ll Cable Tool, J Push Point ❑ Other <br /> Proposed Well Depth tp.0 ft Excavation 1Z 94 in diameter 7 Open Bottom +-;�,6ravei Pack/Gravel Size r in diameter <br /> Li Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter rin Thickness/Gauge/ASTM Sched Zon J Steellastic C Stainless Steel ❑ Other <br /> Grout Seal Dept �20% <br /> Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ent � s) '.1 Other <br /> Grout Placement Method �,P mped .rl Free Fall F1 Other U Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ump Contractor ❑ Other <br /> F'. Concrete Pedestal i'Dimensions:Width ft Length ft Thick in ❑ Christy Box h Stove Pipe <br /> PUMP I-; Submersible[j Turbine 1: 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 /> 7IN�U7VCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209) 953-7697 <br /> SIGNED TITLE C�(s�/VJ� DATE <br /> G <br /> aAC <br /> 1 <br /> / <br /> 4111 wiw <br /> r <br /> RAN j1OA U O N <br /> E I <br /> M10%Ii in <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By `7��� �_ nate — �J SP:;C;A:-WC-E Permit <br /> Pump Inspection By Date L WAIVER Received <br /> Soil Boring Inspection By Dateo str t Well Depth_ ft <br /> COMMENTS <br /> 6 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 171 7 g 4 I� U01.13 3 F <br /> I <br /> EHD WELL/PUMP PERMIT <br /> 4/30/1212 <br />