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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 /> JOB ADDRESSy [l �J �{(nI r�ti CITY/LP L 1 dI 1 CI <br /> D <br /> I 1 �1Z)64-1 <br /> { G0 <br /> CROSS STREET lel S Y� V ) IRV7 APN J6 471 75���'" PARCELSIZE" LAND USE APPLICATION# m <br /> OWNER NAME �u (/\ - [f�' .) ` I�J_��li�t LI rHONE 7Y- / _ 1�y <br /> OWNER ADDRESSt✓� 7 1,� ��17 <br /> CRYISTATE/LP �C <br /> CONTRACTOR \, C% ht (ZI J t� 4 !Qi r1 '� PWME �• 1/�- )779 t /{ c, <br /> CONTRACTOR ADDREss C' 'J C'x 1 CITYISTATE/LP G''1 I V. C-'y C 1 C7 l�-• 1�� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEILP <br /> LICENSE C-57 .C-61 _ 0-09 ._ Other NUMBER'' > -7 ExPIRAT1oN DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED UsE -Domestic/Private )I,Irrigation/Agricultural Industrial Water Quality Monitoring -Soil Sampling/Characterization <br /> -Public Water System <br /> It diff—ro hom Ownar: Wt., em Name nma or ne u <br /> TYPE OF WORK New Weil =Replacement Well Well AlteraWniModification =Other <br /> Monitoring Well(s) #of wells - Soil Boring(s) #of bonrgs -.Geotechnical 8 of bong <br /> Out-Of-Service Well Out-Of-Service Well Renewal -Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION _ <br /> Drilling Method Mud Rotary -Air Rotary Auger Cattle Tool Push Point Other I/d <br /> Proposed Well Depth ()�•L: ft Excavation�_in diameter - Open Bottom Gravel Pack/Gravel Size_ diameter <br /> Conductor <br /> Casing in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter�_in Thickness/Gauge/ASTM Sched _ -- Steel JZ Plastic .= Stainless Steel - Other <br /> Grout Seal Depth >�i ft -: Neat Cement(94/b bagl5-10 gal wafer) Sand Cement `C. j sack mixR gal water <br /> - Bentonite(20%solids) Other <br /> Grout Placement Method XPumped _ Free Fall _ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By4 Driller .- Pump Contractor 2 _. Other <br /> Concrete edestal--Dimensions:Width 7 It Length�_ft Thick in -Christy Box -Stove Pipe <br /> PUMP ubmersible--Turbine - Other HP :.5 f) Pump Set ft Standing Water Level / h <br /> I HEREBY CERTIFY THAT 1 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED <c.• TITLE C� rll if' DATE A <br /> RECF <br /> N��AQU�TI N o <br /> NEA�H p PPII <br /> i X <br /> I LLL <br /> 1�9. <br /> D-EPARTMENT USE ONLY <br /> Application Accepted B Date i. -t'1 It AreaLt"r Employee ID# � L <br /> Grout Inspect-49 ' Date l / D S�Well Perni t <br /> Pump Inspection By �' DateV `s 1�,'I ( 7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date penult/ Invoice# Well ID# <br /> Codes Info By Remitted Service Request# <br /> EHD 43116 /7�/// WELL rPUMP PERMIT <br />