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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 /> • 3-7 til N. Rey h Lo�;� . c q Saga <br /> JOB ADDRESS CITYIZIP <br /> db t-� O <br /> CROSS STREET�1.'-yT�u c n�C Cn 1^/ - \\ APN PARCEL SIZE'3.1LAND USE APPLICATION# <br /> OWNER NAME I Cny 1"`G<'T1'n PHONE H <br /> OWNER ADDRESS O `^ CITY/STATE/LP <br /> CONTRACTOR \,J cA k",�` n PHONE ?,(oq 7 7 a <br /> CONTRACTOR ADDRESS CTY/STATE/LP G"i`\T) (7^ <br /> 9 ; 3 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/GSIT(A�TEEIZJP �] Q <br /> LICENSE C-57 �.C-61 �.'D-09 L Other NUMBER 1 1✓`>- EXPIRATION DATE / ��l 1-I V <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> [LNTENDED USE i DomesticIPrivate " Irrigation/Agricultural 1 Industrial L:Water Quality Monitoring I Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owmr Water System Name U.Mad NaM or Phone Number <br /> TYPE OF WORK New Well r Replacement Well = Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> ew Pum Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary i Air Rotary i Auger I Cable Tool r Push Point n Other <br /> Proposed Well DepthAoDft Excavation_ 14—in diameter Open Bottom X Gravel Pack/Gravel Size /4_ in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Schad Cj 200 11 Steel ]4 Plastic n Stainless Steel a Other <br /> Grout Seal Depth 50 ft Neat Cement(94 Ib bag/5-10 gal wafer) /"Sand Cement 10.3 sack mix17 gal water <br /> i Bentonite(20%solids) i Other <br /> Grout Placement Method XPumped L.Free Fall I Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By XDriller Pump Contractor Other <br /> Concrete Pedestal [Dimensions:Width 3 It Length____3 R Thick_(Q_in i Christy Box :1 Stove Pipe <br /> PUMP Submersible Turbine i Other HP_?1�_ Pump Set G 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 /> MIN M 24 HOUR ADVANCE NOTICE REQUIRED FORINSPECTIONS-PLEASE CALL(209)953-7697 <br /> `J <br /> SIGNED C GtTl TITLE ,Ce- DATE '!j I 17 <br /> 4 31� e <br /> R ti <br /> S <br /> SPA 30 ROW A <br /> DEPARTMENT USE NLY <br /> Application Accepted By Area Employee ID# �1 <br /> Grout Inspectio y ate ❑ SPECIAL Well Permit <br /> Pump Inspection ByDateDr� L1 WAIVER Received`, v <br /> Soil Boring Inspection By Date Constructed Well Depth 4 ft p <br /> COMMENTS P <br /> _ C G' —P <br /> 1 4:6 I Vf 4r a- nbI y M <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# Pi,,.;f <br /> Codes Info B s Remitted Service Re uest# <br /> 2,1 <br /> EHD 43-08 «�:'Q WELL/PUMP PERMIT c <br /> 4(30/12 <br />