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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 /> JOB ADDRESS �k7 ©kms `��o� CITY/ZIP_�0t i r^ <br /> � a <br /> ��e� �iv1 <br /> CROSS STREET APN� 0-3PARCEL SIZE- 1+3 LAND USE APPLICATIO`N'# y� M <br /> OWNER NAME �G-✓�1�� I7{�IR /7/[E/{^LSA 6/ T/ y <br /> PHONE e—Y <br /> OWNER ADDRESS CiU�Ge CITY/STATE/ZIP f d �- <br /> CONTRACTOR n�a s ly s bY L I(,( PHONE <br /> CONTRACTOR ADDRESS [ L C I�Q+�S t1ZC+ CITY/STATE21P <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ><P-57 C-61 D-09 i Other NUMBER EXPIRATION DATE-Z�r7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private I Irrigation/Agricultural LI WtIQAAr alit Monitoring Soil Sampling/Characterization <br /> I Public Water System ►` ' <br /> or <br /> If different from Owner: ater y em MWEI I I V I I t or one um er <br /> TYPE OF WORK XNeW Well I I Replacement Well Well A ��rIf�Iaatiypf ' <br /> I I Monitoring Well(s) #of wells Soil Q�' "x'- fro � hnical ��9/c <br /> I Out-Of-Service Well Out O ervl a etedrG�-a f pair i:a O it6 <br /> I New Pum I Pum Replacement Pum i 2 <br /> LAI 111 IQ <br /> WELL CONSTRUCTION ` 4Q <br /> Drilling Method XMud Rotary Air Rotary Auger Cable Tool n Push Point Other N[' kNv1j��/N CO <br /> Proposed Well DepthOZROft Excavation %Z in diameter I- Open Bottom Gravel Pack/Gravel Size J`�AR? eter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 77 in Thickness/Gauge/ASTM Sched 2990 Steel Plastic I Stainless Steel 1 Other <br /> Grout Seal Depth / py ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> KBentonite(`20%solids) Other <br /> Grout Placement Method umped 1 Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ump 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE '-- <br /> CURRENT <br /> SCURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24�H^OU,R� �A/D��VfA�iNCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> I <br /> SIGNED L . `►(/!/yC (-C td TITLE b-�'-I(IIe'✓, DATES 2��'' <br /> Ip <br /> 1p,41 <br /> 1 <br /> J ) <br /> ( a <br /> t <br /> I <br /> i <br /> r DEPARTMENT UffSE, ONLY _ <br /> Application Accepted By Date l-� C L Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS h <br /> PE Sc Received e / Amount Date Permit] Invoice# Well ID# <br /> Codes Into By Cash Remitted Service Request# <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4/30/12 <br />