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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 ADDRESS ' \�O v {.J CJ t�LI.��1 ,/Y / CRYILP ' `` <br /> CROSS STREET �G11CV"T L n t „2 APN 6 N N-4—I q PARCEL SIZE�LANO USE APPLICATION NQ ^''� / <br /> OWNER NAME L�r<A LcA V C rI PHONE ��7- t Or-76 <br /> OWNER ADDRESS '_ G Mr G CITY/STATE/ZJP ) ^� <br /> CONTRACTOR ��11 P j r 1 11^t�� l mimes 6 yCI — 171 -79 <br /> CONTRACTOR ADDRESS P a i aj �'.�C CITY/STATE/Lr <br /> P `A SS/,3 <br /> SUBCONTRACTOR PHONE 7 <br /> SUBCONTRACTOR AoORE33 CITY/STATEIZIP <br /> LICENSE C-57 C-61 M9 Other NUMBER .�( ICI 7`) 5 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> C]DomestictPrivate Irrigation/Agricultural _Industrial -Water Quality Monitoring Soil Sampling/Characterization <br /> n Public Water System <br /> If dtfterent ham Owmr. a,er ys,era am. <br /> r!�! <br /> ConladNarimcrPtione um r <br /> TYPE OF WORK 0 New Well Replacement Well _Well Alteration/Modification Other <br /> D Monitoring Well(s) #of wells Soil Boring(s) x ar bar'g - Geotechnical a of tnnngs <br /> fl Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> I=New Pum 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 ft Excavation in diameter Open Bottom IGravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched -Steel Plastic -Stainless Steel - Other <br /> Grout Seal Depth ft .- Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mW7 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 Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Suhrnersible Turbine Other HP _ Pump Set % C� ft Standing Water LevelIS-72-1 ft <br /> 1 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 /> MINIMUM 24�PUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED cJ22M-c^- TITLE \. 1 C t' P C'S r CI(°Yi+ DATE - p <br /> l <br /> PAI ) <br /> CF jV�� <br /> Af4R 0 9 <br /> �o ?418 <br /> NVjR -1CO <br /> LryCFPgR�t <br /> EP TMENT U�jEQj0NQ�fJ..Y <br /> Application Accepted By Date--'��� Area4--q- Employee(Dif <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Date (/ Ll I WAIVER Received <br /> Soil Boring Inspection By Date�J-- CConstructed Well Depth It B <br /> COMMENTS ,0 A�LPJ QQ P. y_I{1 C 1(l Cvka.Y ICJ�_�J, Lf J''I t e ram_ 0)h <br /> PE R ChseldYf Amount Date Service <br /> Invoice# Well ID# <br /> Codes Info Cath Remitted Sarvlu Rath <br /> a I til 003170210 <br /> F �S <br /> EHD 43-0e I,/ / WELL(PUMP PERMIT <br /> 4130112 <br />