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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE 1PP/1ERR�MIT CALL <br /> 209 95f3--17697 FOR INSPECTIONS EXPIIRR!E}SS I YEAR FROM DATE(IS(S)UED <br /> JOB ADDRESS I � _� `Y _CITYIZI Ira v • ' l � ,/Z v m <br /> CROSS STREET C�n APN _PARCEL SIZE I L D USE AP LIGATION# A <br /> P l UN m <br /> OWNER NAME w <br /> 'n I HOLE I vi <br /> OWNER ADDRESS 1!� V ITY STATE- P_ C—" G <br /> CONTRACTOR C VL1`14 <br /> /m"n s {'/1 /� H)ONE • V C� <br /> 01 CONTRACTOR ADDRESS 09 T ( <{ CITY/STATE 5Cl <br /> SUBCONTRACTOR /A PHONE •" `'r L <br /> IV <br /> SUBCONTRACTOR ADDRESS / I _�[CITY/S7A7E21P <br /> LICENSE 1" C-$7 C-61 D-09 Othe_�i� NUMBER EXPIRATION DATE / (� <br /> GEOGRAPHICAL INFO ATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE 17 Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water byStem Name L;ontaCt Name or Friona N.mler <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other f'�• <br /> Monitoring Well(s) #of wells Soil Boring #.(boring <br /> Boring(s) s Geotechnical #of borings <br /> Out-Of-Service Well Renewal Cross-Connection Repair <br /> mcium <br /> 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 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 bag/5-l0 gal water) Sand Cement sack mW7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Le lh It Thick in Christy Box Stove Pipe r---N <br /> �04PUMP Submersible Turbine Other HP Pump S ft Standing Water Level jt 1 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 /> MINI M 24 HOUR ADVANCE NOTICE REQUIRED FOPUNSP]E/C�TIOnNS-PLEASE CALL(209)9 -7697 <br /> V <br /> SIGNED TITLE t It Y� `ter!/ tl DATE <br /> IV <br /> ` ED <br /> I J11 j 2016 <br /> IUMNIUL'iAl HEALTH <br /> l!CES <br /> 7-7 <br /> N� <br /> - P A T M E N T U E O N L Y <br /> ' ws <br /> Application Accepted By��W VY/' �t� ate �•V Area��i/(,�[�J Employee ID#'�{'r�f��U <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Cli ate 3� I r0 WAIVER Received <br /> Soil Boring InId?.n By Date Constructed Well Depth ft <br /> COMMENTS /f <br /> G <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Request# Invoice# Well ID# <br /> o a3 67 3 6h 1e yRo� <br /> EHO 43-06 WELL(PUMP PERMIT <br /> 4130'12 <br />