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- t t V <br /> ut <br /> �. 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 /> Sly <br /> c p A N <br /> JOB ADDRESS �//.7 y .V• �I^��L7 CITY/ZIP 7 O m <br /> D <br /> �j v <br /> CROSS STREET Ih tC/?.? PN.2�� yG�►O PARCEL SIZE ya,is LAND USE APPLICATION# m <br /> OWNER NAME / -C A(jVIng A ii �IrZtj"� H -36 Ji <br /> All <br /> t �r <br /> OWNER ADDRESS •' CITY/STATE/ZIP .DG <br /> 1Y L= PHONE ,lo�3—4 y <br /> CONTRACTOR Y' •�► 2�f A�y u <br /> CONTRACTOR ADDRESS a � CITY/STATE/ZIP Zkxh-/,` G- . < dr 3SZ:S <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE rYl-57 j <br /> C 61 i 1 D-09 [7 Other NUMBER V. <br /> iZ �� EXPIRATION DATE S 3i z <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private 1. Irrigation/Agricultural ❑ Industrial Ci Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 11 Public Water System <br /> If different from Owner: Water SystemName ------- ontact acme or Phone Number <br /> TYPE OF WORK PY1Vew Well eplacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I- Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> I; New Pump F Pump Replacement ❑ Pump Repair 17 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method JY,Mud Rotary Ci Air Rotary C Auger ❑ Cable Tool U Push Point ❑ Other <br /> Proposed Well Depth 'y 00 ft Excavation /' in diameter ❑ Open Bottom Ji)'l Pack/Gravel Sizein diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in T Icknes / auge/ASTM Sched 540W 2! Steel *-Plastic 1; Stainless Steel ❑ Other <br /> Grout Seal Depth� S Jeat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack ii gal water <br /> �entonite(20%solids) !I Other _ <br /> Grout Placement Method *"Vbmped -i Free Fall h Other (' Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller &OPbmp Contractor ❑ Other <br /> Concrete Pedestal-Dimensions:Width ft Length ft Thick in it Christy Box ❑ Stove Pipe <br /> PUMP I- Submersible[; Turbine 1; 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 C PENSATION LAWS. <br /> MI MU 4 R DVANCE NOTICE REQUIRED FOR INSPECTIQNS- PLEASE CALL(209) 953-7697 <br /> SIGNED ,141TLE CkOr r2 S � DATE V - . .1 ` 2 <br /> C <br /> 15T,U <br /> 41 <br /> r � <br /> i <br /> i <br /> � E I <br /> M N <br /> A Jil <br /> •• • ��___;_f I I i I I ��L 1 I i i ! 1 I <br /> JE ARTMENT SE�0NLY <br /> Application Accepted Date `v Area q Employee ID# b � <br /> Grout Inspection By Date h ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> '-"" Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS STIP <br /> Cp 1 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> ISO <br /> 311-7-110 S Uh¢ <br /> L_ <br /> EHD 4-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />