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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 /> us <br /> y a tp (, � <br /> Jos ADDRESS <br /> J�3 i7 C (J!-Ll7ad V"?Vj �� CIrrIZIP L-u hf rc l ^Z3 y <br /> G a <br /> CROSS STREET L � PARCEL SIZE 0 73,J"LjAND USE APPUCATrON# <br /> w <br /> OWNER NAME L 1 fn lra err r[ PHONE rry� <br /> OWNER ADDRESS I /tU �`/A� Z5q /} CrTYlSTATEIZIP e^ , �a ��f T95 2! O <br /> CONTRACTOR C+4 V' i7 f1� 1 G ! /TSS /a ,�Leerfv GG/1 PHONE ' -Ciq <br /> CONTRACTOR ADDRESS o Z T n J, ri-c 414 CITYISTATE01' <br /> SUBCONTRACTOR N! PHONE <br /> SUBCONTRACTOR ADDRESS 'r CiTYISTATE01' <br /> LICENSE .5(C-57 C-61 D-09 Othef NUMBER VO EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE DcmestidPrivate IrrigationlAgdcultural Industrial Water Quality Monitoring x Soil SamplinglCharaciedzation <br /> Public Water System <br /> N dieerenl Imm Cmwer wate,5y.iem Nae on ac ame a one um er <br /> -------------------------------------- <br /> TYPE gF WogK New Well ReplacementWell Well AlterationWodificatien Other oar�dn <br /> Monitoring Well(s) #of wells Soil Sodng(s) a of bonrgs )(Geotechnical sa <br /> Out-Or-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casirig <br /> WELLCONaTRUC o <br /> Drilling Method Mud Rotary Air Rotary XAuger Cable Toot Push Point Other <br /> Proposed Walt Depth 10 ft Excavation a _in diameter Open Bottom Gravel Pac.VGravel Size in diameter <br /> Conductor Casing In diameter I Conductor Casing Depth h <br /> Well Casing Diameter_in ThicknesslGaugelASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seat Depth ft Neal Cement(94 Ib bagJ5.10 gal wefvr) I Sand Cement sack mlxl7 gal water <br /> Sentonite(20%solids) XOther fv Gµ!`fr, r, rt✓� `fzh µ,{ll <br /> Grout Placement Method Pumped Free Fall Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By Driller Pump COntraclor 01her <br /> Concrete Pedestal Dimensions Width ft Length It Thick n Christy Boz Stove Pipe <br /> PvMP Submersible Turbine Other HP Pump Set —ft Standing Water Level 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANNOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED �' TITLE l L ? - — DATE <br /> r� <br /> x <br /> x <br /> moa <br /> 6 �L <br /> DE ARTMENT USE PNLY Employee ID# <br /> Area �{ <br /> Application Accepted By = <br /> Date ��� ', -_ �("G <br /> Grout Inspection Hy Date SPECIAL Well Permit <br /> Pump Inspectiol Date _ WAIVER Received <br /> Date. Z-%- Con cted Well Depth _ ft <br /> Soil Boring Ins B n _ <br /> COMMENTS )C 'f <br /> ar 7•r3•>Ji,.,.�. '12:.- a �! "l u <br /> RPE7 CheckpI Amount Permit/ Invoice# WeII ID#Cash Remitted <br /> Date Service R uest3`d`t c1 `" 52W 7 7 C� <br />