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1 <br /> WELL/PUMP PERMIT <br /> SAN JOAOVIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-0232- <br /> (209) <br /> NON-REFUNDABLE PERMIT CALL 12091953-7697 FOP INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 0 <br /> Joe ADDRESS p ('���tt�GG�--� w r r Y�,JS '�E �� <br /> (►�3n l k- /�y� Cm/LP_ 0� <br /> CROSS STREET APN ` /'l/-7_/-O) D <br /> PARCEL SIZE p <br /> 1/y/� (�ra 3�LAND USE APPLICATION <br /> OWNER NAME WIVE, <br /> 'IV` {}(i�V //��``11 �/ <br /> �]Fy\ 1 /y�,� ` / n P/H�ONEI_(��/T/ ZJ-I' ISw w <br /> OWNER ADDRESS _ RM LJ3. rC�V(S) {�„`F ZD C(TYISTATEILP <br /> CONTRACTOR <br /> --7 PHONE <br /> CONTRACTOR ADDRESS M) t^ q <br /> {l•�-!}'2 CTrY/STATEIZIP J`'ccl'TLfll (y,q� <br /> SUBCONTRACTOR w QQ.I'�Jyy t' t( PHONES �/ �'I t, /7M <br /> SUBCONTRACTOR ADDRESS <br /> LICENSE -57 C-61 D-09 Other NUMBER I'f -/�' ExPIRATONDATE <br /> GEOGRAPHICAL INFORMATION: CoordlnetesX 7J�b�l Y �)��• SLH")J'! Township ZS Range (DtF Section_ <br /> INTENDED USE Domestic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring WOiI Sampling/Characterization <br /> Public Water System <br /> I!r)iaeroM hum Ownor a er y5 em ama o a me or <br /> one unwer <br /> TYPE OF WORK New Well Replacement Well Well Aheratien/ModiBcatibp Other <br /> !Monitoring Wellls) #of wells /toil Bonnpjs) _ Geotech <br /> sol bonngs <br /> - mwl <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cmss-Connection Repair <br /> New Pump Pump Replacement Pum pair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary lLger Cable Tool I Push Point Other <br /> Proposed Well Depth Z() It Excavation'_in diameter C Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameterm in Thickness/Gauge/ASTM Sched -Steel r Plastic Stainless Steel Other <br /> Grout Seal Depth-2-C, It (Neat Cement(94 lb bagl5-10 gal water) C Sand Cement sack m-7 gal water <br /> Bentonite(20%solids/ Other <br /> Grout Placement Method X Pumoed Free Fall Other Retardant/Accelerator(name) <br /> LEDESTAL4 Installed By Driller Pump Contractor Other <br /> 1 Concrete Pedestal Dimensions Width ft Length fl Thick in Christy Box Stove Pipe <br /> PUMP n/Q Submersible- Turbine Other HP Pump Set It Standing Water Level R <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 /> MINIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR/INSPECTIONS <br /> SRNED r1 TITLE I �ZdI'f P�`V FFY.Yii)ATE <br /> I <br /> EN <br /> i CE VFD <br /> z 4 2012 <br /> RonUi''v n" <br /> Cp(JN <br /> WAL <br /> EPARTMENT USE ONLY 5` OE aRTMENT <br /> /p /l <br /> Application Accepted By - - �- Date ?12 Z. Area r / Employee IDX � <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date ! WAIVER Received <br /> Soil Boring Inspection By r lr ! to o _ Constructed Weill.D�s -� ft <br /> COMMENTS <+ 7 C Iv c • <br /> ✓ c% <br /> PE SC Received heckN Amount Data Permit/ Invoice# well IDK <br /> Codes Info B Remitted Service Ra uest 0 <br /> �9 77-1 I 0!0 !� <br /> EH_4306 <br /> 8101146 WELL SUMP PERMIT <br />