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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUF-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 74 <br /> JOB ADDRESS `C/-( v IV 1 i)d CITY/ZIP /1 'lOn ` LIS m <br /> _ y �y o <br /> CROSS STREET C Fr(°mi 1 S I APN I '1 2,G V I PARCEL SIZE"LAND USE APPLICATION 9 m <br /> T I`1 C�L A,r� L P <br /> OWNER NAME PHONE <br /> OWNER ADDRESS ��//-�U��f 1 I- G '!VI C 't7 J / Tel <br /> 1 CITY(STATE/ZIP "' n vim] 5� Z07 <br /> CONTRACTOR Net e r Iy J id 1�AY7 i I P:��� t 1 C l f��',i/ PHONE /�y /3Gn� <br /> CONTRACTOR ADDRESS 11 2- _-�][_ jr�C`7 qCITY/STATE/ZIP,__ �iVQ`i L/r -L� <br /> SUBCONTRACTOR _ _ J� PHONE _ /•/'/ _ <br /> SUBCONTRACTOR ADDRESS "/ CITY/STATE/ZIP <br /> LICENSE '�­C-57 C-61 D-09 Other NUMBER D� I(J(,1 7 EXPIRATION DATE 11't�— <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Pnvate Irrigatior/Agricultural Industrial Water Quality Monitoring .*Soil Sampling/Characterization <br /> Public Water System_ <br /> If different'mT Oroner Water er System am'— OnIBC 8'n2 Or OOBUT1�a' <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> a c`bo^nqe <br /> Monitoring Well(s) 9 of wells Soil Boring(s). a or sonngs Geotechnical�Z <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary .<Auger Cable Tool Push Point Other <br /> Proposed Well Depth 15"Zy ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter f Conductor Casing Depth R <br /> Well Casing Diameter in Thickness+GaugefASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gat water) Sand Cement sack mix17 gat water <br /> Bentonite(20%solids) x Other ��'I Ck nq C tJ° '^�t u rI it er C-n,,re�e L.•f1L1 p�ru <br /> Grout Placement Method Pumped Free Fall Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions.Width It 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 /> MINIVU 24 FOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE %�� -� r n DATE 2-, <br /> Ly <br /> <44 <br /> I <br /> i <br /> 1 <br /> DPARTMENT US O�yNLY <br /> Application Accepted-BI, Dale L - LL Area C� l _ Employee ID# <br /> Grout Inspection By Date _ SPECIAL Well Permit <br /> Pump Inspection By <br /> Date WAIVER Received <br /> Soil Boring Inspection By, L Date_7i�1 / Constructed Well Dep ft <br /> COMMENTS �U <F C �– . ', 60 i A t <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> EHD 43.06 WELL"PUMP PERMIT <br /> 4/30112 <br />