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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 FAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT jA I ��I/�C jALL 2.0}9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �JOB ADDRESS G' Z, 1�z- //��/V �� CITY/ZIP ke/Fek 5 :51_�V' r <br /> J <br /> CROSS STREET diAPN 0? ZS PARCEL SIZE ?LAND USE APPLICATION# <br /> OWNER NAME �As ,,,yam- <br /> - � � �J� P�HONE <br /> OWNER ADDRESS �f,r'f7�///®�JL7�'L l?.� CCIITY/STATE/ZIP�J�JtttX-7XLA <br /> CONTRACTOR O /I¢ PHONE a <br /> -�/ /''���Q`IL� _ <br /> CONTRACTOR ADDRESS �!�D /1�,_� G�(}�� / CCITY/STATE/ZIPr>�/�-^� Z/1' <br /> SUBCONTRACTOR S- 4S �+l'7 � J _ PHONE !)L,r S4F 1 -4 <br /> SUBCONTRACTOR ADDRESS _ / CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER -I-�*'1/1-�� EXPIRATION DATE -- <br /> GEOGRAPHICAL INFORMATION: Coordinates X __ Y, _- __ Township _ Range _ Section_ <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Walar yStem ame Contact Name or Phone Number <br /> TYPE OF WORK Now Well {,'Replacement Well Well Alteralion/Modification Other <br /> Monitoring Well(s) _ #of wells Soil Boring(S) _ e of honngs Geotechnical Ir of bom,gs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump PLImp Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rota Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth_ -' ft Excavation /Z in diameter Open Bottom 'Aisravel Pack/Gravel Size in diameter <br /> Conductor Casing _in diameter / Conductor Casing Depth <br /> Well Casing Diameter-4�1_ in Thickness/Gauge/ASTM Sched 4!:�_47tV Steel Plastic Stainless Steel Other__ <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement _sack mW7 gal water <br /> I Bentonite(20%solids) Other <br /> Grout Placement Method 14Pumped free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller---lump 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 h <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 CONTRAC-ORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM C <br /> W104 <br /> ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95/3-7697 <br /> SIGNED �� / r_� TI .E- --/ ''>F' - DATE <br /> VAI -1 <br /> Op- <br /> -� <br /> 5 � � <br /> - ) <br /> 99 _ <br /> C� > - <br /> /; <br /> JAY <br /> ---I <br /> DEPARTMENT USE ONLY G <br /> Application Accepted By v` at �fJ��_ Area Employee ID# <br /> Grout Inspecti6n c — Date 0 SPECIAL Well Permit <br /> Pump Inspection By G'� c s`� Date r� I WAIVER Received <br /> Soil Boring I,nsption By —_ Date Constructed Well Depth <br /> COMMENTS /O/ <br /> PE Sc Received �- @CkYl Amount Permit/ <br /> Codes Info B - (.`as, Remitted Date Service Request ill Invoice N <jy <br /> '�. rj <br /> (.y <br /> Lou oyc� 49'/ 42--11 5- .°° -7 1f. kS 5-keo 7g0 <br /> L�1 <br /> EHD 43-06 WELL-/PUMP PERMIT <br /> 4/30/12 <br />