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WELUPPMP PERMIT <br /> .SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTI, 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT JPALL 209 953-7697 FOR INSPECTIONS EXPIR S 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP m <br /> D <br /> CROSS STREET �/c"tr� _, <br /> APN �/ `/13—d PARCEL SIZE LAND USE APPLICATION#> 7X <br /> J�/ n <br /> OWNER NAME (50/17 6 PHONE L<–7 (� <br /> / /7J <br /> OWNER ADDRESS CITY/STATE2IP . l %S 2,37 <br /> CONTRACTOR �- G(1��� /PHONE .5 7/� 2 2-S <br /> CONTRACTOR ADDRESS /V ? CITY/STATE/ZIP- <br /> SUBCONTRACTOR + f`1 (/ • PHONE J �'� - _7 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE yam`57 C-61 D-09 Other NUMBER 310,11 EXPIRATION DATE �� C <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK >K[ w Well Xleplacement Well 1 Well Alteration/Modification I i Other <br /> I i Monitoring Well(s) #of wells I Soil Boring(s) #of borings I Geotechnical #of borings <br /> Out-Of-Service Well I Out-Of-Service Well Renewal I I Cross-Connection Repair <br /> New Pump Pump Replacement I ' Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method<Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 00 ft Excavation _I 4L in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Z '; Steel Mastic I Stainless Steel I Other <br /> Grout Seal Depthl&ft Neat Cement(94 Ib bag/5-10 gal water) Band Cement `L",_� sack mW7 gal water <br /> I Bentonite(20%solids) I 1 Other <br /> Grout Placement Method Pumped 1 Free Fall I Other 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By AeDriller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP *::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 /> JOACUIN 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 , ati TITLE DATE <br /> C + <br /> i <br /> EN I N E I L <br /> N <br /> JEA HTMENT U E ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date ��C. ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> ' F1 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> 3 (,� �' 2 sghgl av3�b 2 <br /> WELL/PUMP PERMIT <br />