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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 PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 7 "J '` (^�- i�-e` y,l CITYIZJP <br /> II 11 (� 0 <br /> CROSS STREET L 1 17 e IZ D- APN_I pp /��lV �� PARCEL SIZE /-, LAND USE APPLICATION# m <br /> OWNER NAME �; D i \ 7 �: vi l 1 PHONE t-I`I i0 -35c;3 <br /> OWNER ADDRESS M CITY/STATE/ZIP -7 <br /> CONTRACTOR n I7 1 r 1-t 1Qn�I (PHON1E �/�CI - � / 7 jq <br /> CONTRACTOR ADDRESS -0 171 o 7, I 7� CfTYl5TA7E/LP (,-CA` � ` A ��J C^J <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE ,C-57 C-61 D-09 Other NUM19ER < J 5 ExPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE DOmestir(Private Inigation/Agricultural Industrial Water duality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If d,ff r R from Owner. WIA.Sys t- ame o a .—or um <br /> TYPE OF WORK , New Well Replacement Well =Well AlteratiorUModification _ Other <br /> Monitoring Well(s) #of wells =Soil Bonng(s) •of borings Geotechnical rt of borings <br /> Out-Of-Service Well - Out-Of-Service Well Renewal Cross-Connection Repair <br /> i•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 )-1 c) it Excavation ' in diameter Open Bottom 4 Gravel Pack/Gravel Size 1%11 in diameter <br /> �-i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad C I 7ci., Steel ;C Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixf7 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 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 /> MINIMUM 24 MOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ` � " TITLE v C c DATE <br /> i < T <br /> J <br /> N ENT <br /> VED <br /> N <br /> OUNT, <br /> TAL <br /> MENT <br /> E <br /> R T M E N T USE ONLY G� <br /> Application Accepted B Date ( 2, Area t Employee ID# � <br /> Grout Inspection By Date O SPECIAL Well Permit <br /> Pump Inspection By -, �ci X, Date 7'i(��,(.. 1 WAIVER Received •�-I1 <br /> Soil Boring Inspection By Date Constructed Well Depth 2 1 It <br /> COMMENTS <br /> PE Scceived Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By- Cash Remitted Service R uest# <br /> fNa <br /> EHD 43-06 <br /> WELL(PUMP PERMIT <br /> /i3$b is''' -4 /-S w-�00yOVAW\ <br />