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WELL/PUMP PERMIT <br /> r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186B EAST HAZELTON AVENUE-STOCKTON CA 95206-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)9533-,7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED <br /> JOB ADORES9 L�`f__ ,'i�.c' _ CHY21P <br /> CROSS STREET�)r/4t±tI:W 1T !,!%'�Z�/5(•?17APN � JrJ PARCEL SIZE tkJD USE A`PPUCATION p �a <br /> OWNER NAME PHONE:-/I�-' '!j.- "'1r;i- G@I <br /> OWNER ADDRESS GTY/STATEIZIP :�'ifJ <br /> CONTRACTOR Y1r` t/ rrlcIPHONE 2f <br /> CONTRACTOR ADDRESS r/� .S- ^t�_�%��'r`� <br /> �'�` CITY/STATEIZIP r7:-""c.�rJ'}, �'� ��P �!� <br /> SUBCONTRACTOR lel uJ 17r,1Tj lsj+-� PHONE 'L U`'` f.^i'-)�7c� <br /> SUBCONTRACTOR ADDRESS .� Y 1i�jC-tom �fI/`1.:. l�r'- CITY/STATEIZIP <br /> *C J.c:�IL'(G•.-V C,'F, !(;�j G.IS� <br /> LICENSE ' -57 D C-61 J D-09 =Olher u` J`` Nu1;IHER EXPIRATION DATE T <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section_ ♦� co' M <br /> INTENDED USE =Domcstk/Private J IrdgatlonlAgrlcullural ;ndustdal 0 Water Quality Monitoring D Soil SamplhglCharacterizellon m jL --I mow <br /> -Public Water System CD <br /> IldtlferoN Oom Uvner, er oy om nme on c eme or ^.um__r r:.F <br /> taFfsn- <br /> TYPEOFWORK =NewWefl =ReplacemenlWeB ❑WeIINleraliorJModilfcaGon Ixother{ter(,?cq,wN5 4t]�L[, � <br /> _Monllorin Wel s 0 of wells U Soil Bain s s°r d« <br /> 0 K) 9() ro+ u Geotechnical tiOlb°r� � � `•� �s� <br /> _(hit-O(�eMce Well O Out-Of-Ser.Bce Well Rer;eWel O Crass-Comwctlon Repair QQQ <br /> -New Pump Pump Replacement n Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> � <br /> - :—:3 <br /> < <br /> Drifting Method -Mud Rotary_ jL Air Rcfary y Auger n Cable Tool n Push Point F Other 063N <br /> Proposed Well Depth '�3 ft Excavation JL—YI diameter 7 Open Bolcom :]Gravel Pack/Gravel Size In diameter CD <br /> e <br /> -Conductor Casing In diameter / Conductor Casing Depth fl t 1Q.•�• <br /> Well Casing Dlameter in Thickness/GaUge/ASTM Sched 7 Sleel O PlaetlC O Slalnless Steel 0 Other <br /> GroutSeal Depth ''; ft U Neal Cement(94 lb baglr-10 gal water) U Sand Cement Sack mix17 gal Wolof `� �• CD <br /> ;"enlonite(20%sQ9ds) D Other <br /> Grout Placemerit Method U Pumped 0 Free Fall D Other ]Retardant/Accelerator(name) <br /> PEDESTAL Installed By L Drlllar U Pump Contractor O91er `•1:3 <br /> -Concrete Pedestal-Dimensions;Width it Length ft Thick in 'Chrlsly Box l Slove Plpe j <br /> PU!AP -Submorsibler Turbine 0 Other HP Pump Sed ft Standing Water Level R 3 L �• �r�u+�": <br /> I <br /> HEREBY CERTIFY AT I HAVE PREPARED THIS APPLICATION AND THAT TIIE WORK WILL BE GONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COU 40 NANC LAWS.AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE 19 <br /> CURRENT AND ACTIVE ITH THE CALIP RNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> W OR,CERS wMPENSATICN LAWS. <br /> �00 <br /> /1 ' i M 201.111 ADVANCE NOTICE REQUIRED FI"INSPECTION EASE CALL(209}9 13-76 7 <br /> TITLE l Ii �L DATE 3(. I S <br /> EFR <br /> _ <br /> r 9 <br /> trill 1 . <br /> i ; e <br /> V c. <br /> Qv <br /> `. <br /> Coby <br /> a�� '`' I I SA ENV1A�rn a�TN1F� <br /> DEPARTMENT ,USE ONLY <br /> Application Accepted By I Date i i- 1 ) Area Employee iDR <br /> Grout Inspection By Dale t G SPECIAL Well Permit <br /> Pump Inspection By Dar 17 WAIVER Received <br /> Soil Boring Inspectlan By Date Constructed Well Dop/h ft <br /> COMMENTS <br /> PE SC Received flee Amount el Permit/ Invoice# WeIIID# <br /> Codes Info B Ramified Service Request# <br /> TT <br /> (Si 57 :&.,; ( IS 3a <br /> EH0 43-06 <br /> 413W12W iL.R111.IP PERMIT <br />