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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 /> N <br /> JOB ADDRESS I oo >= • L�a�� V r CITY/ZIP 5+C C- m <br /> D <br /> :V, '�77�� 0 <br /> CROSS STREET C-10—IL-,. ` APN 1-J 9 ^ZZt✓- I(o PARCEL SIZE iq•"5�-tAND USE APPLICATION# m <br /> fn <br /> '-VOWNER NAME � I- r I y.q � PHONE G -516- 03 ZZ— <br /> OWNER ADDRESS &'556 Yu" .&A4'S S4 -,A *r 3a Z CITY/STATE/ZIP <br /> CONTRACTOR GL Cr'.,'ck.'. T-: ` PHONE `i, I �{OZ-3735 <br /> CONTRACTOR ADDRESS S Pet So �� +� CITY/STATE/ZIP [ttDlw�t I �f G(�ef I C��1�j�24 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE I_I C-57 ❑ C-61 O D-09 CI Other NUMBER ql(' l EXPIRATION DATE •ZC> <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section _ <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name on ac ame or Prione Number <br /> TYPE OF WORK I I New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> u Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I 1 Geotechnical #of borings <br /> LI 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 L Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom I.1 Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched L1Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> I ! Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 1-1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> [.1 Concrete Pedestal Dimensions:Width ft Length ft Thick in 11 Christy Box 11 Stove Pipe <br /> PUMP I I 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 HOUR ANC NOTICE REQUIRED FOR INSP5CT'IONS - PLEASE CALL (209) 953-7 97 <br /> e—Maj • ,, <br /> SIGNED TITLE Qj .+_LY DATE it <br /> y <br /> II VT <br /> PI <br /> ns of let ad SA <br /> , mna l Et`► cU <br /> 1d t L <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By �''/' AW1� ( T404� Date /1 � /� Area O0 I el 91 Employee ID# A <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received el Chec_W Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> 436'� <br /> END 43-06 WELL/PUMP PERMIT <br /> 4/30/17_ <br />