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14 WELL/PUMP PERMIT <br /> S VN 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 /> JOB ADDRESS C� [1lJ /`'/. T-kr CITY/ZIP � Cl m <br /> ila <br /> CROSS STREET 1✓ r a_Ta t(� APN PARCEL SIZE LAND USE APP CATION# ` 7�p <br /> OWNER NAME (J �J V < y <br /> 1�.� � �.,�1 PHON�� <br /> OWNER ADDRESS CITY/STATE/ZIP t� C A <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE I C-57 !' C-61 I D-09 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 99ft� Irrigation/Agricultural I Industrial u Water Quality Monitoring i I Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water ystem Narae Contact Name or Phone Number <br /> TYPE OF WORK I New Well I Replacement Well i I Well Alteration/Modification i Other PAWARIT <br /> I i Monitoring Well(s) #of wells i I Soil Boring(s) #of borings I Geotechnical <br /> I Out-Of-Service Well AOut-Of-Service Well Renewal i Cross-Connection Repair �nGGl�..r• <br /> New Pump f 1 Pump Replacement Pump Repair I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary 1 Air Rotary I Auger Cable Tool Push Point Other SAN JOAQUIN COUNTY <br /> Proposed Well Depth ft Excavation in diameter i Open Bottom i Gravel Pack/GravAHHiAATH DEPAF"MgWer <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 1 Steel Plastic Stainless Steel I Other <br /> Grout Seal Depth It Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine 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 COMPENSATION LAWS. <br /> MI U4 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED /� TITLE A Lwk f�'�� U`-"`c `r DATE!, <br /> �� I <br /> O <br /> v <br /> 5 <br /> rT i <br /> SStC- <br /> rr <br /> i <br /> r <br /> vo71"T 71 <br /> �� ARTMENT US ONLY <br /> Application Accepted By, -Date 27Area .A Employee ID# <br /> Grout Inspection By n r'r1�/► Date ❑ SPECIAL Well Permit <br /> 0t-4V_R Rp Inspection By I/U(/�11I11A� Date 13c,. 'Z ❑ WAIVER Received <br /> Soil Boring Inspection By Date Co tructed Well Depth ft <br /> COMMENTS f i%t l I 0l6CJ CIA-1-45--/t y P Pte- 41 2 V <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> 01b -73C <br /> Co 115 <br /> V1 Jos <br /> EHD43-06 y �/Q� WELL/PUMP PERMIT <br /> 4/30/12 �wU(� <br />