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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 /> I <br /> Jos ADDRESS` '11� I `'1 1 1W ) `_ i CIn/�LP� t� <br /> CROSS STREET )�� S 1� I�T7 APN F)G���yJ J PARCEL SIZE"'Z'I• ID USE APPLICATION S <br /> n r <br /> OWNER NAME g ` t'- <br /> ry� C � yt kLf�C� PHONE .. ( -7 C,' y <br /> OWNER ADDRESS G'� 1� r\ QnBTATE/ZIP �/C C �1 "1 �'_/•�' <br /> �i - <br /> CONTRACTOR NE 3 779 PHO <br /> CONTRACTOR ADDRESS C C'x V / CrrY/STATE/ZID C—',I i C A '2 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP ` (� <br /> LICENSE C-57 C-61 -. D-09 _ Other Nuel.—I'1 E...DATE 7- <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE _DOmesMVPrivate jt-InigadoIVAgricu turas =Industrial =Water Quality Monitoring --Soil Sampling/Characterization <br /> Public Water System <br /> Itdlternkton Owner. Wiftr 3yswm eme cnla NO"o <br /> TYPE OF WoR Pew Well Replacement Well _ Well Alteration/Modiftation Z Other <br /> Monitoring Wei(s) !of wells = Soil Boring(s) eofborings -Geotechnical eof borings <br /> Out-Of-Service Well - Out-Of-Service Wei Renewal -Cross-Connection Repair <br /> New Pump Piano Replacement =Pump Repair =Raise Well Casing <br /> WELL CONSTRUCnON _ <br /> Drilling Method Mud Rotary Air Rotary - Auger -Cade Tool - Push Point - Other i 1A <br /> ProposedWell Depth 90C ft Excavation I_in diameter -Open Bottom ',)�Gravel Pack/Gravel Size diameter <br /> s Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter q in Thid.ss/Geuge/ASTM Sched C�-9ZL_ =Steel Plastic =Stainless Steel -Other <br /> Grout Seal Depth 5C, ft Neat Cement(94 1b bag/5-10 gal water) Sand Cement IC sack mixR gal water <br /> !Bentonite(20%solids) _Other <br /> Grout Placement Method XPumped _Free Fall _Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By A Driller _Pump Contractor:7 .: Other <br /> Concrete Pedestal"Dimensions:Width .7 ft length ftThick in ChristyBox Stove Pipe <br /> PUMP —,*,Submersible-Turbine -Other HP_:Z � Pump Set ft 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED 1 / C.Z•ZN-T.• TITLE V t Y'i;' S Ct Cn DATE <br /> AFc <br /> 16C 1) <br /> LA 2-171-1N 0ov/k C <br /> I �� QyrA <br /> I L <br /> ' I- I I r 111---- L <br /> I <br /> elley <br /> �7. <br /> DEPARTMENT USE ONLY {�{ <br /> Application Accepted By Date Area Employee IDN <br /> Grout Inspection i Date D SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth tt <br /> COMMENTS <br /> PE x Received CheciW Amount Permitl Invoice E I Well IDN <br /> Codes Info Cash RemMed Date ServkOR uestN <br />