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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 /> to <br /> JOB ADDRESS V V 1 V� ��� f\f/ 7 CITY/21P I GrA1 i D <br /> 'r �-7 0 <br /> CROSS STREETN; 1./�V I �\ APN �r / - S PARCEL SIZE ( )S LAND USE APPLICATION# A <br /> r+� <br /> N <br /> OWNER NAME gc>/ � ,I��+-�, ,f(f 11 PHONE / y <br /> OWNER ADDRESS ` ( C�I f,✓-�`/L-/"r-f ` �/ L'V/a 7 CITY/STATE/LP q L t 2 2 <br /> CONTRACTOR \i'-� `. 7 l I^1 Inc) PPH-OyN�,E 1 ,C) -�7 79 <br /> z <br /> CONTRACTOR ADDRESS C ox '-1" CITYISTATE/LP l J_,1 1 I CA g S G J <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEILP f Z <br /> LICENSE C-57 /-,C-61 D-09 Other NUMBER I EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE Domestic(Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> It different from Owner. Water System Name o eName or ne — <br /> TYPE OF WORK New Well Replacement Well Well AlterationiModificabOn Other <br /> Monitoring Well(s) #of wells Soil Bonng(s) 9 of bocrgs Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal -Cross-Connection Repair <br /> New Pump )<Pump Replacement Pump Repair XRaise 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 Gravel Pack/Gravel Size in diameter <br /> Conductor C?sing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter L in Thickness/Gauge/ASTM Sched &,Steel C Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/610 gal wafer) C Sand Cement sack mix/7 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 ubmersiWe Turbine Other HP Pump Set ft Standing Water Level- I ft <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 �7 L rZ�u~ TITLE `+ C L 1 f I:7 I Y DATE C) 17 <br /> V <br /> mo <br /> S Alt <br /> W <br /> 'v C <br /> G <br /> J <br /> N <br /> L <br /> EP RTMENT U-SE ONLY <br /> Application Accepted By / Date O^ Area < < Employee ID# <br /> Grout Inspection By �., Date PECIAL Well Permit <br /> �� <br /> Pump Inspection By!-1"kt, Date \ ,c i WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check* Amount Date Permit/ Invoice# Well ID# <br /> Codes Info 8 Cash Remitted Service Re uest# <br /> c1 (00 7 c111 l4 03b2L <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />