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r <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.3420 <br /> r <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �(„ 3 CITY/ZIP f/L4l�V c D <br /> CROSS STREET 11 11t APN Z55PARCEL SIZE 11 g� UND USE APPLICATION <br /> /#�/ � <br /> OWNER NAME illli2ZG. i0 <br /> 0 51irmaell �Y` O PHONE -6a> <br /> �/�ry <br /> OWNER ADDRESS i ` D (i(f,J4V /JCITY/STATE/ZIP 1... <br /> CONTRACTOR I ,���7] `��/ // PHONE 61 7 <br /> �yQ =3 <br /> CONTRACTOR ADDRESS L/ i? b�C 11JCITYISTATEIZIPUT(�I i l95A?4 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR SS CITY/STATE/ZIP <br /> LICENSE I C-57 I I C-61 I D-09 I Othef NUMBER4�. EXPIRATION DATE <br /> GEOORAP L INFORMATION: COordlnate Y Township_ Range Section_ <br /> INTENDED USE IDomestic/Private I Wrigation/Agricultural I Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water ys em Name on ac am e or Phone Nt.tmoer <br /> TYPE OF WORK ew Well i Replacement Well I Well Alteration/Modification i Other <br /> F Monitoring Well(s) #of wells F Soil Bonng(s) z of borings - Geotechnical #of bodnge <br /> I Out-Of-Service Well I Out-Of-Service Well Renewal i Cross-Connection Repair <br /> ew Pump I Pump Replacement I Pump Repair i Raise Well Casin <br /> WELL CONSTRUCTION V� <br /> Drilling Method I Mud Ro ary I Air Rotary I Auger i gjIble Tool I Push Point i Other ' Z t v <br /> Proposed Well Depth ft xcavatiir—247—:in diameter I Open Bottom rae <br /> vel Pack/Gravel Size diameter <br /> C Conductor Casing ,,, ameter / Conductor Casing Depth I ft 1 <br /> Well Casing Diameter in Thickness/G e/ASTM Schad 750 eel Plastic Stainless Steel Other <br /> Grout Seal Depth ft eat Cement(94 lb bag/5-10 gal water) I Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) I I Other <br /> Grout Placement Method Pumped I Freel` I Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By fffDriller ump Contractor� F Other <br /> I Concrete Pedestal i Dimensions:Width ••l ft Length ft Thick in I Christy Box I Stove Pipe <br /> PUMP 'ubmersiblei urbine i i Other HP ,l. Pump Set i(; ft Standing Water Level ft <br /> I HEREBY RT THAT I H E P ARED HIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAOUIN O ORDINANC ST E LAW , AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT ACTIVE WITH E LIFOR A CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKER PENSATIO S. <br /> O A OTICE REQUIRED FOR CT ONS-PLEASE CALL(209)953 69 <br /> SIGNEDTITLE (/ - DATE <br /> to XI <br /> T <br /> t <br /> 14 <br /> Or OUNTY <br /> TAL <br /> NMENT <br /> L <br /> Vek <br /> FFEF <br /> ## <br /> 11 ry� DEPARTMENT] USE ONLY _ <br /> Application Accepted By D ( ry 1 1- Date 1 L Area Employee ID# <br /> Grout Inspection By Date hSPECIAL Well Permit <br /> Pump Inspection By X rYN,A Date - WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well De th ft <br /> LG/S COM ENLL9 C J <br /> r1,4 <br /> PE SC Received ec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> Co NO Y4??5 11 <br /> EHD 43-06 �.� �� .Q�Lei t� WELL/PUMP PERMIT <br /> 4/30/12 <br />