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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 /> m�/ 0�7 I 7G�m'j <br /> JOB ADDRESS / <br /> D <br /> CROSS STREET AR1,12 A `►/PN O GS U' U PARCEL SIZE LAND USE APPLI(C�ATION# m <br /> /� <br /> OWNER NAME /1 &k © /! ' / /P,H.00NN�E��� <br /> OWNER ADDRESS /377 L fC�Uf/ /� , <br /> �C� CITY/STATE2IP <br /> CONTRACTOR �� �,eil,` I nef me PHONE � 77Z Z-7 5 77 <br /> CONTRACTOR ADDRESS � �/' `�/ CITY/STATE/ZIP /; Teyyy <br /> SUBCONTRACTOR _ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE XC-57 r7 C-61 i 1 D-09 II Other NUMBER 70 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE A Domestic/Private Ci Irrigation/Agricultural ri Industrial ❑Water Quality Monitoring U Soil Sampling/Characterization <br /> I I Public Water System <br /> If different from Owner: Water System Name ontact Name or Phone NU 1►/ <br /> TYPE OF WORKNew Well p(Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) s of borings ❑ Geotechnical—�� <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair "tR (/f 2018 <br /> ❑ New Pum rI Pump Replacement Li Pump Repair ❑ Raise Well Casingv <br /> WELL CONSTRUCTIONENVj Uy Co <br /> ry <br /> u, <br /> Method P Mud Rotary ❑ Air Rotary n Auger Ll Cable Tool LI Push Point ❑ Other HST RONMFNT61 <br /> UN <br /> Proposed Well Depth -3f)o ft Excavation 1Z /y in diameter ❑ Open Bottom Dt Gravel Pack/Gravel Size / EjVjjl diameter <br /> U Conductor Casing- in diameter / Conductor Casing Depth _ft <br /> Well Casing Diameter- in Thickness/Gauge/ASTM Sched s/7K/ 7 U Steel pCPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 1011" ft F Neat Cement(94 lb bag/5-10 gal water) �rSand Cement sack mix/7 gal water <br /> LI Bentonite(20%solids) tl Other <br /> Grout Placement Method V Pumped ❑ Free Fall ❑ Other U Retardant/Accelerator(name) <br /> PEDESTAL Installed By 7(Driller 7 Pump Contractor /, ❑ Other <br /> Concrete Pedestal Dimensions:Width Length yz ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP F Submersible Turbine I' 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 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 714 <br /> HOU V NC OTICE REQUIRED FOR SPECTIO/NS- PLEASE CALL(209) 953-7697 <br /> SIGNED TITLE r DATE <br /> LA L4, <br /> a <br /> PARTM ENT USE' ONLY l �] <br /> Application Accepted By Date <br /> �U Area / / Employee ID# Wan <br /> Grout Inspection By Date tL� 1 I D ❑ SPECIALWell Permit <br /> Pump Inspection Byrl <br /> Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth TO 0 ft <br /> COMMENTS X, dome5 4;C We IL be-101 U SP v i t rr; g 1 . 1' <br /> O e S <br /> PE Sc Received Check Amount Permit/ <br /> Codes Info B — sh Remitted Date Service Request# Invoice# Well ID# <br /> 3�1 1 <br /> HS <br /> y� S <br /> 70 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />