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WELL/PUMP PERMIT <br /> C'AN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDAB ERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> m <br /> JOB ADDRESS CITY/ZIP r!n L'A 9,S 2'3 n <br /> CROSS STREET /7/610 J TI APNPARCEL SIZE .'T' LAND USE APPLICATION#_ <br /> //�� . - -r m <br /> OWNER NAME f`'-AI�IF!!�� _rZ��S PHONE 209 661 ' <br /> OWNER ADDRESS / &&' lw CITY/STATE21PS.S /c7-Mlek �I� 2� s-- <br /> CONTRACTOR 1 v l ;� t i a'�((7(�lj�j� ! /L PHONEW9 772 -27,5-7 <br /> If <br /> CONTRACTOR ADDRESS�� 11 U. Vt ll 1 CITY/STATE/ZIP 11 Cg ��!�jS GI5252 <br /> SUBCONTRACTOR ���A1� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP g <br /> LICENSE C-57 C-61 D-09 i Other NUMBER EXPIRATION DATE 7 / <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE �CDomestic/Private 1 Irrigation/Agricultural i Industrial Water Quality Monitoring i Soil Sam pfng/Characterization <br /> Public Water System _ <br /> If different from Owner: Water System Name ontact Name or Phone Number <br /> TYPE OF WORK XNew Well I iReplacement Well Well Alteration/Modification i Other <br /> Monitoring Well(s)__ _ #of wells Soil Boring(s) #of borings i Geotechnical_ #of borings <br /> Out-Of-Service Well i Out-Of-Service Well Renewal i Cross-Connection Repair <br /> Now Pump i Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method / Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 34L'�O ft Excavation in diameter i Open Bottom 'ravel Pack/Gravel Size 3/1a in diameter <br /> 1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched ST�2 Z/Z/ Steel /,YPlastic i Stainless Steel i Other <br /> Grout Seal Depth A ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement /0•,3 sack mW7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method X Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By X Driller Pump Contractor� Other <br /> Concrete Pedestal Dimensions:Width f•rr ft Length ft Thick _4(,�E__in Christy Box Stove Pipe <br /> PUMP )0 Submersible Turbine Other HP Pump Set / d— 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 /> MINIMU ADVANCE N I REQUIRED FOR INSPECTION5.- PLEASE CALL(209)953-7697 <br /> SIGNED TITLE ��{�< C DATE '7` 3r/—/7 <br /> 77 <br /> C2017 <br /> s4N Jo QUIN COOTY <br /> Lp <br /> NT <br /> D)EARTMENT7UE NLY <br /> Application Accepted B Date Area Employee ID# rnno <br /> Grout Inspection By Date ❑ PEC AL Well Permit <br /> Pump Inspection By i 41DateIs, I - ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 5 � ft <br /> COMMENTS LJ JAw 19 % ha,/ -A hoc -1"4 '4"' a.to/yr� <br /> 30t-Z-S iv do. C' cd u �. , c�1�1 N6 cwtr <br /> _.-_ l G w� <br /> PE SC Rec ived Check#/ I Am6kint Permit/ `l <br /> Codes Info By Cash Remitted Date Service Request# Invoice# Well ID# <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4/30/12 <br />