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WELUP,UMP PERMIT <br /> SAN JOA <br /> QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT% 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT JPALL 209 953-7697 FOR INSPECTIONS E PIR S 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS (,+/ CITY/ZIP "t/ _ m <br /> D <br /> CROSS STREET �y/^-/c:LJ APNy �/���d PARCEL SIZE C LAND USE APPLICATION#_ <br /> m <br /> OWNER NAME ,n <br /> �' 0!�I L 1� PHONE [ ci / <br /> OWNER ADDRESS / J�X1 j,Ir St Akr CITY/STATE/ZIPep . C� <br /> CONTRACTOR [O'�.� + PHONE , 3 2 iJ(' <br /> CONTRACTOR ADDRESS J CITY/STATE/ZIP— <br /> PHONE <br /> SUBCONTRACTOR ^ r^ <br /> � `� ___;17/20 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ,)<-57 C-61 D-09 Other NUMBER ?�.3a , EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private Irrigation/Agricultural i 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 >IM. w Well replacement Well Well Alteration/Modification i Other <br /> i Monitoring Well(s) #of wells i Soil Boring(s) ft of borings Geotechnical #of borings <br /> I Out-Of-Service Well I Out-Of-Service Well Renewal Cross-Connection Repair <br /> i New Pump I 1 Pump Replacement i Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger 1 Cable Tool Push Point i Other <br /> Proposed Well Depth )d� ft Excavation in diameter Open Bottom 1 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 >Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Band Cement `0;��_ sack mW7 gal water <br /> i Bentonite(20%solids) i Other <br /> Grout Placement Method Pumped i Free Fall i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By lkf Driller Pump Contractor i Other <br /> i ' Concrete Pedestal Dimensions:Width ft Length ft Thick=in i Christy Box i Stove Pipe <br /> PUMP 104ubmersible i i 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 CEFTIFY 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 x � TITLE LJ� �� DATE <br /> i <br /> IA <br /> NIP <br /> IS I <br /> C <br /> i <br /> s <br /> u J <br /> EN v1 R ON E T L <br /> A0JEARTMENT USE ONLY <br /> Application Accepted By ORPIDate d� Area 4141Employee ID# <br /> Grout Inspection By Date i f I SPECIAL Well Permit <br /> Pump Inspection By Date Ll WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS /� 1 <br /> 1 <br /> PE SC Received Check#// Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Remitted Service Request# <br /> 3 <br /> 'Woo 3 y b 2 <br /> E WELL/PUMP PERMIT <br />