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WELL/PUMP PERMIT <br /> SAN JOAO6iN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)465.3420 <br /> NON-REFUNIDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS O Qr CA oG CC.".CROSS r STREET U I API �O_ ` 'PARCEL SIZE f�G LAN /APPLI/CAATION# <br /> OWNERNAME PHONq "1 O <br /> OWNER ADDRE88 CITY/STATE/ZIP L/111 ��\) <br /> CONTRACTOR r ' ••�� W V y�C.. � PHONE <br /> CONTRACTOR ADDRESS 1/Y Y 10 Q iJ j2y CrrYlSTATE21Pq4 iAIS <br /> SUBCONTRACTOR / PHONE / <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP / <br /> LICENSE 57 C-61 D-09 Other NUMBER EXPIRATION DATE 0 J rn <br /> GEOGRAPHICAL INFORMATION: <br /> Coordinates X Y Township_ Range_ Section_ (`1 � Q N <br /> INTENDED USE DOmesticlPrivate IrrigatiOn/Agricuftural Industrial Water Quality Monitoring Soil Sam pling/Characterization 1711 <br /> Public water system ) <br /> CI/hw1 <br /> Iftlilfereirt from Owner. a Sysame ame or one um er .� <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other p <br /> #of borings i of borings <br /> Monitoring Wells) #of wells Soil Borings) Geotechnical <br /> 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 /> 7l^tt�/� :5 , <br /> Drilling Method XMud R Air Rotary Auger <br /> �q Cable Tool Push Point Other �+ co Phi <br /> Proposed Well Depth ft Excavation -in diameter Open Bottom Gravel Pack/Gravel Size % �' in diameter D <br /> ICD <br /> i .�� <br /> Conductor Casing in diameter / Conductor Casing Depth ft tryY7 <br /> Well Casing Diameter L in Thicmess/Gauge/ASTM Schad j�Steel Plastic Stainless Steel Other L]Y Q.. '..�• <br /> Grout Seal Depth ")0 It Neat Cement(94 lb bag/5-10 gal water) Sand Cement (O i > sack mix17 gal water 'J (SIL <br /> Bentonite(20%solids) Other - srscrsx' <br /> Grout od.�Placement MethPumped Free Fall Other Retardant/Accelerator(name) =3 _ <br /> PEDESTAL Installed By Driller Pump Contractor Other (�_ �•"tom r--t• sai <br /> Concrete Pedestal Dimensions:Width It Length 8 Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level <br /> IN <br /> 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 AMID ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATIQN LAWS. <br /> MINIMUMI/ `��A ffAl r REQUIRED FOR I PECTIQ4 PLEASE CALL(209)953-7697 <br /> SHINED tk v v' r 1 TITLE V.fq CIL M2E DATE 04 120-I <br /> I <br /> C <br /> P <br /> r: ryNT <br /> iA 11. <br /> FD <br /> JUL 21 <br /> r ¢r SA,,,r <br /> Tni M10 <br /> Ey,JA QUryy i <br /> HE4L� 4.;,tiM <br /> stn �DEPARTMENT USE ONLY ^� - '.J <br /> Application Accepted By IV 1- M'fL�'ri` Date 'l 0 Area �3 Employee lD# I�} f <br /> Grout Inspection By Date _ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Insp lion,By Date Constructed Well Depth R Jf I <br /> CQQ�MMENTS ! `Gtz <br /> r U ti�t <br /> PE Sc ReceivedAmount Dam Permitl Involve# Well ID# <br /> Codes Info B Remitted Service Request# <br /> 436ho7g34-I ? s�o�7ooX <br /> EHD 4306 WELL/PUMP PERMIT <br /> 4130/12 <br />