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WELL/PUMP PERMIT ( " I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 9205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS !/!_ <br /> -- - - -------. CITY/ZIP <br /> tlo <br /> 1 CROSS STREET_ 5 P A"P/N ,6,7- <br /> �O6 7-z -V PARCEL SIZE LAND USE APPLICATION q_ <br /> OWNER NAME <br /> PHONE <br /> OWNER ADDRESS � O1ZCI7Y/STATE21P 7. <br /> (�.7_ <br /> J!,1J2� <br /> CONTRACTOR �� <br /> _ -A (IJSa ___ PHONEJ 3 4/7ZS <br /> CONTRACTOR ADDRESS 0lb�/ 1 -7 CITY/STATE/ZIP /, 00per7 <br /> SUBCONTRACTOR <br /> �i <br /> - &A1AA4, PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE21P__ `�J1 <br /> LICENSE .e.C-57 C-61 D-09 Othef NUMBER__ 7 g L- EXPIRATIONDATE ` <br /> GEOGRAPHICAL INFORMATION: Coordinates Y Township__ Range-_-__ Section____ <br /> INTENDED USE Domestic/Private rngation/Agricuflural Industrial Water Quality Monitoring Sal Sampling/Characlerization <br /> Public Water System <br /> If dieemnl from Owner ----Water SysiemName -�ontac�Jeme or FFone Aumlier -- - <br /> TYPE OF WORK -'-NewWell Replacement Well Well Alteration/Modification Other P Vr...._- <br /> Monitoring W911(s)_. M of wells Soil Boring(s) _ 0 of bonngs Geotechnical R � l <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair VEp <br /> ew Pum <br /> Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,'WMud Rotary Air Rotary Auger Cable Tool Push Point Other_ A JOAOLII'; _ <br /> Proposed Well Depth__Sj.)___it Excavation _ in diameter Open Bottom ICGravel Pac ME�ITAL_ in diameter <br /> UNT <br /> Conductor Casing in diameter / Conductor Casing Depth___--- ___1l �aRT11i <br /> Well Casing Diameter 3 in Thickness/Gauge/ASTM Schad_1-20 Steel sCPlaslic Stainless Steel Other_____.__ <br /> Grout Seal Depth­5-6--It Neat Cement(941b bag/5-10 gal water) and Cement_ ?o-3__ sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method 4Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Ye Driller Pump Contractor Other lr <br /> Concrete Pedestal Dimensions:Width_�ft Length It Thick - in Christy Box Stove Pipe <br /> PUMP -e-Submersible Turbine Other HP2 iy 7 Pump Sel 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 /> MINIMUM 24 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953--7697 <br /> SIGNED .ti- __. TITLELY—" DATE <br /> 1 1## 1+ <br /> EP RTMENT USE ONLY '/�/ <br /> Application.Accepted By L,'-�' Date A <br /> AreaEmoloyee IDRy!�b _Grout Inspection By Date I I SPECIAL WBII Permit <br /> Pump Inspection By !1 Date 11 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth _ ___At <br /> COMMENTS <br /> PE Sc Received Amount Date Permit/ Invoice k Well IDM <br /> Codes Into B Cash Remitted Service Request M <br /> EHO 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />