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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ) u--j ` V CITYIZIP L--.I 1'L.j c/i . ag n <br /> //---7 7 / G <br /> (CROSS STREET f� /A'PN (JV `/ L�3V G 1 PARCEL SIZE VC-LAND USE APPLICATION# m <br /> OWNER NAME UI Lp) p�CJI J^f' (�Oc-k I jL L( PHONE Z[)� 3 & 7p / 7[�� N <br /> OWNER ADDRESS Z O a o Z 1,v LIG'`d(1 1n`-O CITY/STATC/ZIP <br /> CONTRACTOR �I �r'hJ��O W(� 1)iz (I r/LI.I PHO//NJJE G r^ <br /> CONTRACTOR ADDRESS / 1` l l CITY/STATE/Z)P <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 L C-61 O D-09 a Other NUMBER <br /> N 3 <br /> 'EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> FLTENDED USE Dontestic/Private C Irrigation/Agricultural L3 Industrial D Water Quality Monitoring 0 Soil Sampling/Characterization <br /> Public Water System <br /> It different from Owner Water SyStern Narne Contact Na.-e-off ono um er <br /> TYPE OF WORK 9 New Well Peplacement Well CI Well Alteration/Modification C Other <br /> ;)Monitoring Well(s) #of wells ❑Soil Boring(s) 0 of borings Geotechnical "s of borings <br /> Out-OfSarvice Well 0 Out-Of-Service Well Renewal j Cross-Connection Repair <br /> New Pump O Pump Replacement ❑Pump Repair u Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 5 Mud Rotary fj Air Rotary 0 Auger D Cable Tool - Push Point 0 Other <br /> Proposed Well Depth "G it Excavation If 1, r, in diameter I Open Bottom O Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft i <br /> Well Casing Diameter[2.- in Thickness/Gauge/ASTM Schad XSleel O Plastic 71 Stainless Steel 0 Other <br /> Grout Seal Depth >:jp ft 0 Neat Cement(941b bag/5-10 gat water) Sand Cement sack mix17 gal water <br /> ._Bentonite(20%solids) 0 Other <br /> Grout Placement Method C Pumped 17 Free Fall G Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller 0 Pump Contractor 0 Other <br /> :j Concrete P d sta)Dimensions:Width It Length ft Thick in f✓,Christy Box -1 Stove Pipe <br /> PUMP D Submersible,--,Turbine 0 Other HP Pump Set It Standing Water Level ft <br /> I <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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIV WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPE TION LAWS. <br /> MINI 24 HOUR ADVANCF,NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE Qu•'K'r�� DATE / 2_ <br /> If <br /> En M.1.N 11 WT <br /> PA TMENT U E ONLY <br /> Application Accept B �' ate til Area Employee ID#:! <br /> Grout Inspection 3 " Date I SPECIAL Well Permit <br /> Pump Inspection By Dale WAIVER Received <br /> Soil Boring Inspection By Date Constructed Wolf Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> EHD 43-00 WELL/PUMP PERMIT <br /> 8104,1W <br />