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TU\4L'a `/CjIr-' iZ-�J -I� r,5y•� <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN CouNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 45203-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 7 n <br /> JOB ADDRESS c'TY/z,P t rl cel e c-j 1 <br /> 0 <br /> CROSS STREET kJ S 1'} "� 7 I�n AP 1�C�`�" ��� PARCE/L�SL:EeL"C� I�(LAND USE APPLICATION 3t <br /> OWNER NAME ` G (J( \ I .0 1 I l >✓ `�j'PHONE �(- �'1^ 1-7c•� <br /> OWNER ADDRESS CI 1J 1)� `�I I I `D' CLTYISTATFJZtP �/C <br /> CONTRACTOR \a `-'t C 7 1 I 1 L� PHONE ���rr��_ �7 79 <br /> CONTRACTOR ADmsz C ��L'X l c� CrTY/STATE/Z1P G I'L I CA C I S 4'. �2 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS ISCITY((/STATE/ZJP <br /> I 7 <br /> LICENSE C-57 C�1 _0-09 � Other NUMBER' ExPIRATION DATE - ) - 1 ' <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE _OOmeabC/Prtvate )L lrrigatioNAg6culturai :Industrial Water Quality Monitoring =Soil Sampling/Characterization <br /> Public Water System <br /> If tl'Rerea Iran Owner W.tr bytmNa— .Clt N.—or ne u <br /> TYPE Of WORK New Well =-Replacement Wel Well Alteration/Modification Other <br /> S of borinpa -_Geotechnical A 0r 6n's <br /> Monitoring Well(s) >K of wells _ Soil Borirtg(s) <br /> Out-Of-Service Well - Out-Of-Service Well Renewal - Cros"onnection Repair <br /> New Pump Pump Replacement = Pump Repair = Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method>(Mud Rotary - Air Rotary -Auger Cable Tool - Push Point - Other I/d <br /> Proposed Well Depth CTC-(j R Excavation�_in diameter 7 Open Bottom Gravel PacklGravel Size_ diameter <br /> ConductorCasingin diameter / Conductor Casing Depth R <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 91 = Steel �t Plastic =Stainless Steel _Other <br /> GroutSeal Depth r�; R Neat Cement(9416 bag 5-10 gal water) Sand Cement C. sack mixt7 gal wafer <br /> _i Bentonite(20%solids) L Other <br /> Grout Placement Method Pumped Free Fall _Other _Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller _ Pump Contractor 7 : Other <br /> ConcrvG ed*stal -Dimensions:Width J R Length�_R Thick in -Christy Box :Stove Pip* <br /> PUMP ubrnersible-Turbine Other HP =Pump Set R Standing Water Leval �l R <br /> I HEREBY CERTIFY THAT 1 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 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 ( `v <br /> SIGNED TITLE \j /C Ch T- DATE <br /> �J <br /> rK <br /> S <br /> O� L <br /> OEC ' <br /> PN�O 00 , 4 <br /> S PL�H a�P <br /> N� C V <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID* <br /> Grout Inspection By Date :1 SPECIAL GII Permit <br /> Pump Inspection By Date .1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS <br /> PE Sc Received CheckN Amount Permit/ Invoice M Well ID# <br /> Codes Info B ash Remitted Data Service Request <br /> M <br /> 4 /4W AM— <br /> , <br /> / <br />