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': � �FM <br /> 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 /> 7y 1 1 /� <br /> JOB ADDRESS .I 1 W sCI`y n � K V CITY/ZIP Loa 1 , cp, I D <br /> 1 11J, 0 <br /> CROSS STREET ►V «� Z APN C -- " PARCEL SIZE I�"f LAND US APPUCA710N# m <br /> S/f��2-q 32Ir <br /> OWNER NAME I � j 1 PHONE ^ ( /, <br /> OWNER ADDRESS 'V u 1/'� V\C A��"1'7vl 1� V�'/`/�� CITY/STATE/ZIP ✓C(� 1 1 zCC A <br /> ,CONTRACTOR � I I. y D C /L1/I1 �N O - / PHONE /4: l/- 37!\7q z <br /> CONTRACTOR ADDRESS DG GX 1 `�' CITY/STATE/ZIP� c^ J�J� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY//S�TAT((EJZIP <br /> LI1 <br /> CENSE ��G57 C-67 D-09 Other NUMBER 2��CI�J ExPIRATiON DATE 1 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE Domestid �In <br /> Private igatioNPgricultural - ndusthal Water Quality Monitoring Soil Sampling/Characterizationdap� <br /> Public Water System oe AE� <br /> If AiRererrt hom Owrxr. e m ys em eme eme or rro u <br /> TYPE OF WORK y„New Well = Replacement Well __ Well Alteration/Modification Other Al Monitoring Well(s) #of wells _ Soil Boring(s) •°loonngs Geotechnical sof ,/O 008fQ <br /> Out-Of-Service Well Out-Of-Service Well Renewal -Cross-Connection Repair /v UN�, <br /> New Pum _ Pum Replacement _ Pum Repair Raise Well Cas 7 <br /> WELL CONSTRUCTION 7` qL <br /> Drilling Method '.Mud Rotary Air Rotary Auger Cable Tool Push Point Other �ENr <br /> Proposed Well Depth ft Exca ratlon� in diameter Open Bottom Gravel Pack Gravel Size i��i n diameter <br /> Conductor Casing in diameter I Conductor Casing Depth It <br /> Well Casing Diameter f� TIiicknese/Gauge/ASTM Sched CO L-C Steel /C Plastic Stainless Steel - Other <br /> Grout Seal Depth 41�fO Neat Cement(94 Ib bag/5-10 gal water) /,Sand Cement sack mixt]gal water <br /> _Bentonite(20%solids) _ Other <br /> Grout Placement Method,,Pumped Free Fall . Other Retardant/Accelerator(name) <br /> PEDESTALInstalled By Drifler Pump Contractor_ Other <br /> Concrete Pedestal Dimensions:Width `� ft Length ft Thick n Christy Box Stove Pipe <br /> PUMP Submersible- Turbine -Other HP Pump Set it 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 /> MINS I_MVJW-24 HOUR ADVANCE NOTICE REQUIRED FOR`INSPECTIONS-_+PLEASE CALL(209)953-7697 � <br /> SIGNED �('�`"`' TITLE V 1 C a DATE <br /> u <br /> oft <br /> 1 <br /> PAR M E N T USE O LY <br /> Application Accepted By r Date Area Employee ID# <br /> Grout Inspection By ( Date ZI / SPECIAL Well Perrnit <br /> Pump Inspection By 1 l j�'0- ( Date �1�2 J WAIVER Received <br /> Soil Boring In on By Date Constructed Well Depth it <br /> COMMENTS NN`� 'O' C y � L�� y1 <br /> PE SC Received Ch Amount Date PermfU Invoice# Well ID# <br /> Codes Into Remitted Service R uest# <br /> PGS <br /> Q `b d 70Gh 70GPOi <br /> EHD 43-06 WELL rPUMP PERMIT <br /> V30/12 <br />