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E WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953--7697 FOR INSPECTIONS <br />1 YEAR FROM DATE ISSUED <br />Joe ADDRESS <br />�C <br />n <br />N <br />{^\EX/PIRES <br />� � N !I\.D// � CITYfZIP <br />`-7 <br />ay <br />�hJ <br />� 3 4�1!9&ANO <br />CROSS STREET G.. <br />41 �A n <br />A- ✓ <br />1\ <br />APN D 07 <br />- - <br />/ PARCEL SIZE <br />USE APPLICATIONS- <br />o.,J <br />U <br />4OIi�/( <br />i cf <br />WNER NAME <br />Jn <br />n b <br />PHONE <br />OWNER ADDRESS <br />/ <br />RV CITYISTATE17JP <br />AN"ytpj CA qd' o <br />CONTRACTOR <br />361^ -;?77q <br />P <br />Ct <br />4 <br />/PHONE <br />!'` <br />G}i i +� C J-1 � 3y <br />CONTRACTOR ADDRESS <br />�C <br />Jf <br />CITY/STATE/LP <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CrTYISTATE/ZIP <br />LICENSE C-57 <br />-61 <br />D-09 <br />Other <br />NUMBERAM333 <br />'7 <br />7 , <br />EXPIRATION DATE -3 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />WENDED USE )<DomestidPdvate Irrigation/Agricultural : Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water systern Nerre uordact Na,ne or ne NUM130,r <br />TYPE OF WORew, Well - Replacement Well _ Well Alteration/Modification Other <br />Monitoring Well(s) if of wells Soil Boring(s) s °f b0fl�e - Geotechnical a of bonrgz <br />Out -Of -Service Well Out -Of -Service Well Renewal I Cross -Connection Repair <br />Drilling Method-/ Mud Rotary Air Rotary Auger Cable Tool I Push Point - Other <br />Proposed Well Depth '&375 it Excavation 1 2 in diameter - Open Bottom �LGravel Pack/Gravel Size ,�a - in diameter <br />Conductor Casing in diameter / Conductor Casing Depth / it <br />Well Casing Diameter � in Thickness/Gauge/ASTM Schad C i Ci) Steel Plastic _ Stainless Steel Other <br />Grout Seal Depth � Ci G ft Neat Cement (94 lb bag/5-10 gal water) ){Sand Cement Sq < sack mixrl gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other -: Retardant / Accelerator (name) <br />PEDESTAL Installed By riller Pump Contractor Other <br />yC Concrete Pedestal - Dimensions: Width 3 ft Length ---T- Thick = in Christy Box Stove Pipe <br />PUMP '4Submersible - Turbine Other HP Y 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 />EP RTMENT US NLY <br />Application Accepte DD Area Employee IDR <br />Grout Inspection �l� - SPECIAL W@II Permit <br />Pump Inspection By Date 1 �. _.: WAIVER R@C@IV@d t <br />Soil Boring Inspection By Date T Constructed Well Depth > ft <br />COMMENTS ]EACAV Ad lr--f JL, <br />PE SC Received Checka4 Amount Permit/ Invoice it Well 10* <br />Codes Info B Cash Remitted Pate Service Rs uestil <br />` <br />" IG - <br />-77 <br />t <br />ZMn'OEL <br />,� 'D' U <br />WELL !PUMP PERMIT <br />4f3OP2 <br />