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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> M (/� 0 <br /> Jos ADDRESS `h CITY/ZIP j��U 9530 1 D <br /> CROSS STREET f`►$M APIA q$-Q g-0 3 3 PARCEL SIZED$ V LAND USE APPLICATION 1= <br /> OWNER NAME CLnn;n ; PHONEd09 - 83a- <br /> OWNER ADDRESS SJM E CITY/STATE/ZIP 71 X710 <br /> CONTRACTOR De 1 a )In p f fl C' PHONE 209 ) 466-9625 <br /> CONTRACTOR ADDRESS 6 4 6 S. California St CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> I LICENSE C-57 CXC-'3'i D-09 : Other NUMBER, 1055434 EXPIRATION DATE 8/1 6/2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private u Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name ontact; ame or Hhcne Nuinuer <br /> TYPE OF WORK '❑ New Well ❑ Replacement Well :i Well Alteration/Modification ❑ Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) of borings Geotechnical N <br /> Out-Of-Service Well Out-Of-Service Well Renewal ❑ Cross-Connection Repair ECE�VE <br /> New Pump ❑ Pump Replacement Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION 2020 <br /> Drilling Method ❑ Nlud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other SAN <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel PacWGravei Size ENi„AQ_V coo <br /> IVI❑ Conductor Casing in diameter / Conductor Casing Depth ft HEALTH DEPAIR <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other MEN <br /> Grout Seat Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) E. Other <br /> Grout Placement Method 1-1 Pumped C Free Fall '. Other Retardant/Accelerator <br /> PEDESTAL Installed By ] Driller :: Pump Contractor C Other <br /> Concrete Pedestal Dimensions:Width It Length It Thick in Christy Box �i Stove Pipe <br /> PUMP Submersible❑ Turbine Other HP Pump Set ft Standing Water Level It <br /> 1 HEREBY CERTIFY THAT I HAVE PRE=PARED 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 COI`491ENON LAWS. <br /> If 24 HOUR NDVH. <br /> SIGNED ter/ TITLE CEO DATE U <br /> i <br /> Pump is located under <br /> the bushes/trees <br /> • <br /> y � � <br /> • <br /> u e ^rt^ :.- D O ,.. VV L7LwuJ D _ 1A1 6 - 0 0 <br /> - I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date q l570Z Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit: <br /> Pump Inspection By Date 49 to fecu WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedChecw Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> y38a oso ' 77 Ic Zc. <br /> EHD 43-06 <br /> 8I04108 WELL/PUMP PERMIT <br />