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j nihil Scan 0,06 "/"Jv -IuD <br /> WELL/PUMP PERMIT <br /> :rMN 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 /> JOB ADDRESS . CITY2IP S /ate J, (� 7 1 m <br /> �' � �r l�/�`� m <br /> +� D <br /> CROSS STREETPARCEL SIZE31.APN �(]� 31. <br /> £� C-� <br /> LAND USE A/' <br /> PPLICATJION# -7/ m <br /> OWNER NAME �J [ hn (__ ') �I� _63(` �3/� PHONE V <br /> OWNER ADDRESS L, nt CITY/STATE/ZIP <br /> CONTRACTOR �_' cl"rS PHONE 33 f- 7 Ls' <br /> CONTRACTOR ADDRESS p1I Oct L7 CITY/STATE/ZIP 06 IZ <br /> SUBCONTRACTORS PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE amc-C-57 C-61 I D-09 Other NUMBER � S-r- EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE J- Domestic/Private Irrigation/Agricultural _I Industrial a Water 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 'ENew Well Replacement Well Well Alteration/Modification i Other <br /> Monitoring Well(s) #of wells Soil Boring(s) If of borings Geotechnical #of borings <br /> Out-Of-Service Well 11 Out-Of-Service Well Renewal i Cross-Connection Repair <br /> 'New Pump Pump Replacement F Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method*4:4vlud Rotary Air Rotary Auger ,SCI Cable Tool Push Point Other <br /> L70 ft L <br /> Proposed Well Depth 3 Excavation ! in diameter Open Bottom ><3ravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ,� ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Li Steel lPlastic i StainlessSteelOther <br /> Grout Seal Depth _ft Neat Cement(94 lb bag/5-10 gal water) and Cement /V J D sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method< Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By,)+_Driller Pump Contractor F] Other <br /> Concrete Pedestal Dimensions:Width ft Length It Thicr9c in i Christy Box Stove Pipe <br /> PUMP ,�C ubmersible I Turbine ! Other HP ✓ Pump Set ft Standing Water Level It <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 ANG 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 /> MI _IPUM 24 HO ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953--7697 <br /> SIGNED �, TITLE_ y <br /> 6�/�� DATE _`J/ L/ <br /> 0 <br /> Z <br /> 1 <br /> LJ <br /> t (� <br /> OZ <br /> i Z <br /> llr4d U] <br /> r <br /> DEPARTMENT U E N7LY <br /> Application Accepted By Date ( Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection Date W14 1& ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well D th ft <br /> C=TS / L <br /> �r-fit. <br /> PE SC Received Check#/ Amount Permit/Codes Info By mash Remitted Date Service Request# Invoice# Well ID# <br /> �I37 1�� I23 �-17-1(o 52ndNX1 )-- <br /> -1-7- 16 <br /> -.-I - 16 S2 00 7 7�a 0 <br /> I <br /> EHD 43.06 ( WELL/PUMP PERMIT <br /> 4/30/12 <br />