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Yq <br /> 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 <br /> CALL 2(0/�9� 955,33--7697 FOR INSPECTION6 EXPIRES 1 YEAR FROM DATE <br /> ATE ISSUED <br /> f 3 liOV S wl,i L� v/CJ 1 CITY/ZIP "�_T'5x m <br /> J06 ADDRESS T1 D <br /> Go <br /> j CROSS STREET d��e..._ APIN O�»_ _PARCEL SIZE A LAND USE AAPPy^LIICATION,.! --_ m <br /> OWNER NAME (0_T6 Q ..S PHONE <br /> n I Q n- 17� ( ) N <br /> OWNER ADDRESS 8 5� Ise �•VC q <br /> CITY/STATE/ZIP �j K`� , ,C�JQ(l <br /> CONTRACTOR De I ta P11inp I I)ci- _ PFIONE ( 2o9 ) 466-962S <br /> CONTRACTOR ADDRESS 646 S. California St CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE . C-57 1XC-61 J D-09 ❑ Other NUMBER 10 5 5 4 3 4 EXPIRATION DATE 8/16/2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private C Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/ tQrization <br /> u Public Water System PAYMENT <br /> If different from Ov.ner. Water System Name Uontact Name or on <br /> TYPE OF WORK ❑ New Well Replacement Well —7 Well Alteration/Modification U Other <br /> C Monitoring Well(s) ;?of wells Soil Boring(s) %!of borings [. Geotechnical PR n' Z <br /> ❑ Out-Of-Service Well = Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 0 New Pump 7. Pump Replacement %"Pump Repair ❑ Raise Well Casinc SAN JOAQUIN C <br /> WELL CONST RUCTION HEALTH DEPARTMENT <br /> ruNMENTAL <br /> Drilling Method ❑ (Mud Rotary Air Rotary - Auger Cable Tool 7- Push Point C Other <br /> Proposed Well Depth ft Excavation in diameter C 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 C. Other <br /> Grout Seal Depth ft -_ Neat Cement(94 ib bag/5-10 gal water) n Sand Cement sack mix17 gal water <br /> i Bentonite(20%solids) ❑ Other <br /> Grout Placement Method CI Pumped C Free Fall G Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor C Other <br /> C; Concrete Pedestal Dimensions:Width ft Length ft Thick in ._i Christy Box C Stove Pipe <br /> PUMP XSubmersiblo:1 Turbine ; Other HP Pump Set ft Standing Water Level It <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 COMaEN,5ADON LAWS. <br /> / I NIM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE <br /> 'A <br /> r <br /> i <br /> r <br /> Appucauon Hccoptea by employe r' <br /> Grout Inspection By Date _ SPECIAL Well Permit <br /> Pump Inspection By V9,k,> Kag7R.�c, Date Sf 21,122 IX WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS PofCed spirt <br /> PE SC Received Chec / Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> $77 <br /> EHD 43.06 <br /> 8104/08 WELL/PUMP PERMIT <br />