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lIlj N,'1�5G�9 <br /> ZV7 3e )'[ <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 (209)468-3020 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> j p /) N <br /> JOB ADDRESS Z 2 ff 7-0 Al 1 1"� {q W ��- j Clrr/LP A a m� C1 S y7-0 <br /> D <br /> r� <br /> -� Gj 0 <br /> CROSS STREET 1nn 1 Q Ir-t of R APN U (�- 9 -00'S PARCEL SIZE L�_LAND USE APPLICATION# m <br /> w <br /> w <br /> OWNER NAME PHONE <br /> OWNER ADDRESS CITYISTATE/ZiP/1"Oj//�_ <br /> CONTRACTOR N4 0y crI err 1PHON�E ��- 397- ->Z01— <br /> CONTRACTOR <br /> Zn 1 <br /> CONTRACTOR ADDRESS _(V z- �Y10.(A�i�l /td�w'•f CITY/STATERIP L-a I G* �S Z y4, <br /> SUBCONTRACTOR N/!!�/"//r- PHONE *A14 <br /> SUBCONTRACTOR ADDRESS '"//l CITYIrSyTATEIZIIP /r(�l (� <br /> LICENSE r�C-57 C-61 D-09 Other NUMBER 6 LiL0�1 EXPIRATION DATE W 2/ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring XSoil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: azar System Name n ac Name w ne um er <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Sal Boring(s) 0 of bon gs Geotechnical x of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connecdon Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary XAuger Cable Tool Push Point Other <br /> Proposed Well Depth_10-15 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bya�gr5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ?Other Sol 1 GvC/f,,,A r LMJ[r c ncrek Ll <br /> Grout Placement Method Pumped Free Fall Other .1' Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP 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 /> MINIMU 24_HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE h ar or DATE <br /> r <br /> D <br /> E C U <br /> H L <br /> T <br /> QE 11 ARTMENT U El NLY <br /> Application Accepted By Date �✓ Area Employee ID#J!5f!E:�� <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Ins ection Date Constructed Well Depth ft <br /> COMMENTS - `a <br /> &OM f�L > lkiC!!�lG��Lyi7l� ��Ti t Es <br /> PE Sc Received he Amount Date Permit/ Invoice N Well IDN <br /> Codes Info By h Remitted Serrviicce-7R-e-7u-e�st# <br /> .- <br /> EHD 43-M WELL/PUMP PERMIT <br />