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— .7 J <br /> 5 a-i t( 0 LL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT _ BALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �7 <br /> 7777 <br /> �'/ to <br /> JOB ADDRESS / <br /> 7 //T CITYRIP b D <br /> v <br /> CROSS STREET Gn�/YI �+ APPNs��y$D �7� / PPAARRCEEL SIZE<Ad-LAND U APPLICATION# C m <br /> OWNER NAME ,[/ C ��r/!c ��0�` 'v .I�/�_J �_ PHONEc�/� ^��► <br /> OWNER ADDRESS / �yfA�J/ � � Y CITY/STATE/ZIP <br /> CONTRACTORq'f�IVS� PHONE <br /> CONTRACTOR ADDRESS 17/Le 1j'1l <br /> CITY/STATE/ZIP <br /> f 5�_s <br /> SUBCONTRACTOR D.�i/CLei�C� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -5761 1-1 D-09 (7 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township RangeSection <br /> INTENDED USE )dbomestic/Private 1i Irrigation/Agricultural industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 11 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK n New Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 0 Monitoringells) #of wells ❑ Soil Boring(s) #of borings Ll Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> _ New Pump Ci Pump Replacement ❑ Pump Repair 0 Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Method,)VNiud Rotary ._ ❑ Air Rotary 0 Auger Ll Cable Tool 11 Push Point ❑ Other <br /> Proposed Well Depth _ft Excavation in diameter 0 Open Bottom k1Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> N�Well Casing Diameter in Ic}cJr1� /Gauge/ASTM Sched � D Steel �lastic ❑ Stainless Steel 0 Other <br /> to Grout Seal Depth "'(� Neat Cement(94 Ib bag/5-10 gal water) ,Mand Cement sack mix17 gai waier I I <br /> Gk-"1 ❑ Bentonite(20%solids) U Other <br /> Grout Placement Method Limped ❑ Free Fail F. Other I' Retardant/Accelerator(name) <br /> PEDESTAL installed By Cl Driller ^ Pump Contractor 0 Other <br /> Concrete Pedestal .'Dimensions:Width_�ft Length ►-ft Thick in l Christy Box ❑ Stove Pipe <br /> PUMP Anubmersibleu Turbine r; Other HP Pump Set ft Standing Water Level ft <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 AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IF, <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALI. <br /> WORKERS COMPENSATION LAWS. <br /> MI ��ftRVANCE NOTICE REQUIRED FOR INSTECTION -PLEASE CALL(209)9513-71697 <br /> SIGNED ' - TITLEa� DATE <br /> liv — <br /> HEA11U#1 <br /> L __0_� <br /> y D/ <br /> Application Accepted By _ Data Area- Employee ID <br /> Grout Inspection By Date t� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Datta Constructed Well Depth <br /> COMMENTS LJ Iy k �e�,la¢ • [� u.� Gc�ny�c#cL � <br /> ��k 1 le r L pd z� Iola w L -e r <br /> PE Sc Received Che A ountDate Pt rmiV Invoice# Well ID# <br /> Codes Info B as Remitted Service Request# <br /> l`� �l�ll� sr�uo7S�y2 091" 3090 <br /> 437 70 'v q z1 /Iu S o0 5 �2 WV003a_�(e3 i <br /> 11 7 " au 2u lv SK00-7"; 2 I I 00013U 5vo f <br /> IEHD 43-06 WELL/PUMP PERMIT <br /> 4/30112 <br />