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„aa WELL/PUMP PERMIT <br /> A <br /> SAN AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT ]y_ CApLL1 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1001 S• -0� +AQP got. CITYIZIP ��roP/ 9 s330 D <br /> CROSS STREET H*,d d Inye PI Lc”- APIN M-330- JO PARCEL SIZE 3- LAND USE APPLICATION# m <br /> OWNER NAME <br /> 1r LL. troPHONE 01) 114 -7,300 <br /> � f7 p -- <br /> A <br /> // r r1 0 <br /> OWNER ADDRESS �0 04N,e C r CITYISTATEIZIP LA <br /> 1 CONTRACTOR J} PHONE <br /> CONTRACTOR ADDRESS ��+ `�/'�`t"� CITYISTATEIZIP �y <br /> SUBCONTRACTOR S PHONE <br /> SUBCONTRACTORADDRESS Q i� ! CITYISTATEIZIP �"1 <br /> LICENSE I ,C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial Water Quality Monitoring ❑ Soil SamplinglCharacterization <br /> ❑ Public Water System <br /> If different from Owner WaterSystern Name Gontac;t Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well )(Weil Alteratio nlModification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) 4 of borings D Geotechnical #of borings <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 D Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point )�, Other 4?&:se well dead <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> Conductor Casing 17- in diameter I Conductor Casing Depth S-6 ft Sene}vhe <br /> Well Casing Diameter 14 in Thickness/Gauge/ASTM Sche4p C- ❑ Steel ?Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth $—b ft ❑ Neat Cement(94 lb bag/5-10 gal water) �K Sand Cement 10.3 sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other 2.1 (5":eew�en+l <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Dfiller ❑ Pump Contractor ❑ Other <br /> Concrete Pedestal Dimensions:Width __2t.__ft Length it 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 COMPLIANCCj�1(tTH ALL <br /> WORKERS COMPENSATION WS. RECMFNT <br /> NIMUM 24 HOUR ADVANCE NOTICE R QUIRE F INSPECTIONS EI/ <br />` SIGNED - _ —„�I1 DAT <br /> by Y <br /> U11V <br /> 41_ X <br /> Mcn.4" ys/S..el-11 (,—e Apt N7 <br /> Iry LIN 11 <br /> 5-1}1 52"5..-e�6e w:kh <br /> OFLO 7% <br /> ne.L [<..,w,k rpe, Ca YA I1 <br /> SI-.,d."a5 R�ll.. n 74•go) -i <br /> d <br /> Mq 11 <br /> IJew 4"QfC <br /> APP'OY.5'cG v1e55 Lair <br /> 4;11 h be <br /> � p�ced eo.d <br /> ' cvc[u+pknq <br /> _NO GIVE <br /> 4" <br /> g"•�+ �"n sa.,; I I eY;s+;..y y"Pvc- <br /> �..� i•ry z,.l wzu c>sng � <br /> DEPARTME L Y Application Accepted By Date Area Employee ID# 06`G'sl <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By � ' Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#I Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> -A7 'SA_200 CP 0 4, <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8!04108 <br />