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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 96206-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES <br /> I YEAR FROM <br /> FRO�M9�CDATE ISSUED <br /> Joe ADDRESS o;I 6 A Gig t'` clnvel C.'4 G CITYILP r�GaW1 ryll , <br /> t a <br /> C o Q y r v <br /> CROSS STREET ' `1 IyS� 1 V• APN JO D PARCEL SIZE �a LAND USE"APPLICATIONS �p <br /> OWNER NAME k • Wt--I-- P�HyO/NE� 1 5�^ 1'1-1®L a <br /> OWNER ADDRESS 14 <br /> 11 CrtY/STATEIZP <br /> CONTRACTOR �j� ' 1 \l�^�CI PHONE <br /> CONTRACTOR ADDRESS �V I d �F CITYISTATE/ZIP�� �[ 5f�, <br /> SUBCONTRACTOR PHONE J <br /> SUBCONTRACTOR ADDRESS Crry/STATE/Z1P <br /> LICENSE C-57 C-61 D-09 Other NUMBER EXPIRATION DATE 7.. <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE XDomestictPrivate ".IrrigationlAgricuttural _Industrial Water Quality Monitoring -Soil Sampling/Characterization <br /> - Public Water System <br /> If olfrerent from Owmr ys ame — contact Nam of Phone Numbw <br /> TYPE OF WQRK -New Well I-.Replacement Well - Well Alteration/Modification Other <br /> Monitoring Well(s) fol wells Soil Boring(s) s of bonrys Geotechnical I/of bonNs <br /> Out-Of- vice SerWell Out-OT-Service Well Renewal Cross-Connection Repair <br /> New Pum Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method>CMud Rotary Air Rotary ._Auger Cable Tool -Push Point -" Other <br /> Proposed Wall Depth ;06 it Excavation /1 In diameter _Open Bottom (`,ravel Paclf/Gravel Size_l4 in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter fla-in Thickness/Gauge/ASTM SchedGL201 �Steel >(plastic --Stainless Steel Other <br /> Grout Seal Depthbft Neat Cement(94 Ib bag/5-10 gal water) >(Sand Cement IDA SQ�, sack mix/7 gal water <br /> Bentonite(20%solids) :Other <br /> Grout Placement Method - Pumped Free Fall i Other Retardant/Accelerator(name) <br /> JEMaLsr 1 stalled By Dritier .Pump Contractor Other <br /> Concrete ad, <br /> Dimensions:Width�ft Length__l R Thick in Christy Box Stove Pipe <br /> PUMP Submersible-Turbine Othei HPPump 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 /> MINIM�UUM/24 H R ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> INSPECTIONS-PLEASE}CALL(209)953-7697 <br /> Y <br /> SIGNED a�y�t't //Ct-�L��k� TITLE iC- G�Y G{Z 1 DATE <br /> W� e <br /> �5 <br /> i <br /> REGE V ED <br /> i �A� 1g2044 <br /> JOA 0 U E1t1 <br /> Al.- V <br /> TN DEPART F� I <br /> E ARTMENT SE NLY Imo+//ynna��'1 <br /> Application Accepted a Date 0 Aree 'G Employee IDf�%4' [ l7 <br /> Grout Ina + +` ,Date PECIAL Well Permit <br /> Pump Inspection By Date 1 ' ' 7 WAIVER Received <br /> Soil Boring I Wection By Date Constructed Well Depth ft <br /> C��1�,M,��EN�TIS C `� � s S/ >L� / J <br /> PE SC Recei edCheck#/ Amount permit/Codes Info B Cash Remitted Date <br /> ServiceRe usst# Invoice# Wslllq# <br /> 511�1 S L �I <br /> r <br /> v C <br /> EV43-W 7 WELL/PUMP PERMIT <br /> 4/30/11 Pr6 f 7�— <br />