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WELL/PUMP PERMIT" <br /> SAN JOACIUIN 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 /> D <br /> — �A g6 � <br /> JOB ADDRESS CITY/ZIP <br /> �/ L//7 m <br /> Jj 3 d o. o <br /> CROSS STREET E60'TI APN PARCEL SIZE�`�> LAND USE APPLICATION#_ z <br /> P / m <br /> OWNER NAME Zt5 PHONE �D/JN <br /> OWNER ADDRESS /(O� le A tPCITY/STATE/ZIP ��T��/�,e� 9� 2i s� <br /> CONTRACTOR Ivl { /�(��,// ,�,�j'^ �� /C� PHONE Z4Q9 —7-72 -27,57 <br /> CONTRACTOR ADDRESS��e�Ge{r /'�I //(/Y/R ���-1 CITY/STATE/ZIP I Gq <br /> SUBCONTRACTOR � PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 F C-61 D-09 I Other NUMBER EXPIRATION DATE 3 / <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE )CDomestic/Private i Irrigation/Agricultural i Industrial IWater Quality Monitoring Soil Sampling/Characterization <br /> Public Water System _ <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK XNew Well i Replacement Well Well Alteration/Modification 1 i Other <br /> Monitoring Well(s) #of wells i Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well IOut-Of-Service Well Renewal i Cross-Connection Repair <br /> )K.New Pump i Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method / Mud Rotary i Air Rotary i Auger i Cable Tool i Push Point i Other <br /> Proposed Well Depth 3Z�0 ft Excavation 7– in diameter i Open Bottom )�Gravel Pack/Gravel Size in diameter <br /> i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched�l V i Steel APlastic I Stainless Steel I Other <br /> Grout Seal Depth A ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement 1P. 3sack mix/7 gal water <br /> I Bentonite(20%solids) Other <br /> Grout Placement Method Pumped i Free Fall r Other i Retardant/Accelerator(name) <br /> PEDESTAL Installed By X Driller i ! Pump Contractor I Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick J(�P_in Christy Box 1 i Stove Pipe <br /> rPUMP Submersible Turbine i Other HP Z 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 INNSSPECTION$. PLEASE CALL(209)953-7697 <br /> SIGNED TITLE �� ���"{'� `% DATE 7- 51-17 <br /> IN <br /> 09 <br /> n <br /> a� <br /> .. I <br /> i <br /> I <br /> 5 N o aU,,"" , NTY <br /> M <br /> DE ARTMENT U E ONLY <br /> Application Accepted B Date ( Area_CWq0 Employee ID#c1reffor-0 <br /> Grout Inspection By Date ❑ PEC AL Well Permit <br /> Pump Inspection By i Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Pl y had A lae C-A,11l �.o� r6 a. a,to/yrs <br /> 3O -zs `h' d° ��.+,c..� ed u ce. V �l!'a M� ,,wxr <br /> �. s cul <br /> PE SC Rec ived Check#/ Am I nt I I Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> vP 00 C05 <br /> `13 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />