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WELL/PUMP PERMIT <br /> SA.k.',iiiNQL.N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 (209)468-3420 <br /> NON-REFUNDABLE PERMIT CAL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Sn <br /> JOB ADDRESS � V V ��� ' {/ CITY/ZIP �S �/� m <br /> D <br /> t /Dacrc o <br /> CROSS STREET n �" L��.e Lr APN 229 5 PARCEL SIZE LAND USE}�APPLICATION# <br /> no/- LA LT-N L �� PHONE V L y y v> <br /> OWNER NAME JN <br /> OWNER ADDRESS V'I•' /� ,/ ` CITY/STATE/ZIP Ct <br /> iS GILL Jl' <br /> CONTRACTOR OA �A CCiaj: r 0ft,1 Z 1*-, PHONE N7lk' y <br /> CONTRACTOR ADDRESS /y L / CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP �+ <br /> LICENSE NC-57 C-61 D-09 -1 Other NUMBER'S�� �P'r EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural ❑ Industrial Water Quality Monitoring i Soil Sampling/Characterization <br /> Public Water System _ <br /> If different from Owner: Water System Name Contact ame or one Rumber <br /> TYPE OF WORK'ip�ew Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) If of wells Soil Boring(s) n of borings Geotechnical If of borings <br /> v <br /> Q'ut-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> ,5eNew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method"�lud Rotary Air Rotary Auger ❑ Cable Tool Push Point Other <br /> Proposed Well Depth i�ft Excavation 1 S in diameter Open Bottom �avel Pack/Gravel Size in diameter <br /> Conductor Casing Z <br /> C�asing in diameter / Conductor Casing Depth ft <br /> 10 <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Z ' Steel lastic Stainless Steel Other <br /> Grout Seal Depth S"(3 ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement A), sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped L Free Fall i_I Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal I iDimensions:Width It Length ft Thick in i Christy Box Stove Pipe <br /> PUMP Seubmersible 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 /> ,IOAOUIN 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�NjU 24 UR #tVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209))953-7697 <br /> SIGNED !• �' TITLEQ I� A- DATE <br /> 1 ' <br /> IWI yr <br /> flu <br /> r <br /> 0 <br /> J <br /> f p A <br /> 5 <br />` DENARTM. ENT USE CN ! Y 1,,, <br /> Application Accepted By Pit Date 1 Area Employee IDJ!!l t llCv1 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump!nspection B Date D _ [I WAIVER Received <br /> ailiv Soil Boring Insp ction By Date Constructed Well Depth ft <br /> COMME T <br /> PE SC Received Check#/ Amount Permit/Codes Info B Cash Remitted Date Service Request# Invoice# Well tD# <br /> 1*7 /a432 of 511. K 00.1MIN , <br /> ra 6 /.a-132-- S °° I 25R375 132 <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4/30/12 <br />