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� - <br /> N WELL/PUMP PERMIT l <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZE LTON AVENUE-STOCKTON CA 95205 (209)468-5420 <br /> ~ NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �I I� �^' SC1`%Y 1� R v CITY/ZIP Loa I� CiA <br /> CROSS STREET '`+ �G1 APN , - /� PARCEL SIZE' /-�`�`�LAAANNE)Use APPLICAATION# -I m <br /> OWNER NAME 1 1 f�• l�i{r�l 7 7�/ �. J!'k 'P/H�ONP �.�"1 (J ZC'T Ll�i/�`l. m <br /> OWNER ADDRESS �v V`r �`��`<tt<'1[rl 1 V��J/� CnY/STATE/ZW V C c/1 I . C QA -1✓� `1/-110 <br /> CONTRACTOR r 1` , L 1 PHONE /�i• 1-97 7 I <br /> CONTRACTOR ADDRESS_D CJ �GX �� CITY/$TATE/ZIP ��'� ICA SJ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/Z1P 1 C <br /> LICENSE ?4-C-57 /<,C-61 D-09 - Other NUMBER ExPNtAnoN DATE 1 — 1 J <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section �'11 <br /> INTENDED USE Domestic/Private /4,Irrigabon/Agricultural . ndustnal -Water Quality Monitoring Soil SamplinglCharacterization 47 <br /> Public Water System <br /> H dillerere.Owrror. a Ye em me o e eme or ne u j/ <br /> TYPE OF WORK New Well - Replacement Well Well Alteration/Modification Other 4 6 2018 <br /> Monitonng WeA(s) *Of Wells Soil Bonng(s) s or bomps Geotechnical s°I Wft4Jpq <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair H hrVR0� CSU <br /> New Pum - Pum Replacement - Pu Repair Raise Well Casing `^I r �Aj7, NTY <br /> WELL CONSTRUCTION -,1•e. C <br /> Drilling Method-X Mud Rotary Air Rotary Auger Cable Tool Push Point Other FNT <br /> Proposed Well Depth It Excavation in diameter Open Bottom Gravel Pack/Gravel Size V"i - in diameter <br /> -Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter pTTpickness/Gauge/ASTM Sched 0)(-(; Steel �C Plastic Stainless Steel -Other <br /> Grout Seal Depth O"tt Neat Cement(94 lb bag/5-10 gal water) /KSand Cement 16-7 sack mix/7 gal water <br /> _ Bentonfle(20%solids) _ Other <br /> Grout Placement Method _ Pumped Free Fell Other Retardant i Accelerator(name) <br /> PEDESTAL InstioWi <br /> alled By --Driller Pump Contractor _ Other <br /> Concrete Pedestal Dimensions:Width S ft Length ft Thic n Christy Box Stove Pipe <br /> Emp- Submersibie- Turbine Other HP Pump Set ft Standing Water Levelft <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 /> MINIM 24 HOUR ADVANCE NOTICE REQUIRED FOR(INSPECTIONS-'IPLEASE CALL(209)-9/53-7697 � <br /> SIGNED O✓(�rLl.-+. TITLE V 1 C 1`"�n T DATE <br /> 1 <br /> cl <br /> PAR M E N T USEdo LY <br /> Application Accepted By r Date Area__ Employee IDI <br /> Grout Inspection By 11 Date SPECIAL Woil Permit <br /> Pump Inspection By Date ,1221 i 1— ' WavER Received <br /> Soil Boring In on By Date Constructed Well Depth ft <br /> COMMENTS j�� V�� N'�t \,J( Clk��Ol H� <br /> PE SC Received Ch Amount Date PertnlU Invoice# Well ID# <br /> Codes Info Remitted Service R uest# <br /> Q -fl <br /> EHD 47-06 WELL/PUMP PERMIT <br /> 4130112 <br />