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s <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1858 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.1420 <br /> NON-REFUNDABLE PERMIT �r CALLLy 209)9533--7697 FOR INSPECTIONS E,X/PfIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 1� W�C� C i�/l c r r C4 CITY, 1� <br /> D <br /> 0 <br /> CROSS STREET APN © IZE LAND USE APPLICATION# A <br /> OWNER NAME ]/+ /) PHO Z� <br /> OWNER ADDRESS 0 CIO <br /> �/Oyy����� II V n l se <br /> {il•ITYISTATE/ZIP. <br /> CONTRACTOR <br /> W(/urV• ��`� C• 1 Lt �71/Ir_ �tY PHO �— <br /> �4X4 � {�� /��(/'��� ✓/fin <br /> CONTRACTOR ADDRESS• 60-1 n,hU (`U)rtI 41A- -k,NO3 CITY/STATE21P rl& <br /> SUBCONTRACTOR / PHONE <br /> SUBCONTRACTOR ADDRESS C /STATE,I\ZIP '� Z <br /> LICENSE C-57 C-61 D-09 I Other NUMBER V xPIRATION DATE D <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township— Range Section-4yC.,i 0 <br /> INTENDED USE I Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/CharacterizationClio <br /> • r� <br /> �Public Water System +-',. CL's. <br /> If different fron Ovmec Water byStam Name Uorflact Name or Phone um er aaa <br /> TYPE OF WORK �I((Vew Well -1 Replacement Well -1 Well Alteration/Modification _I Other - <br /> #of borings #of bongs Q) p <br /> I Monitoring Well(s) #of wells 1 Soil Boring(s) �Geotechnical ►r _►._ a �� <br /> Out-Of-Service Well i Out-Of-Service Well Renewal 1 Cross-Connection Repair �T�, j � <br /> -1 New Pump i Pump Replacement 7 Pump Repair -1 Raise Well Casing �= N <br /> WELL CONSTRUCTION <br /> Drilling Method YMud Rotary 1 Air Rotary -1 Auger -1 Cable Tool I Push Point -1 Other � EL rj-q <br /> Proposed Well Depth 400 ft Excavation o2O in diameter -I Open Bottom -i Gravel Pack/Gravel Size rt in diam QE <br /> �Conductor Casing in diameter / Conductor Casing Depth ft <br /> V <br /> Well Casing Diameter I4 in Thickness/Gauge/ASTM Sched 0 1 J )(Steel '1 Plastic -1 Stainless Steel 1 Other C <br /> Grout Seal Depth 50 It 7 Neat Cement(94 lb bag(5-10 gal water) 1 Sand Cement IS( sack mix/7 gal C <br /> Bentonite(20%solids) -i Other -L- <br /> Grout Placement Method k Pumped 1 Free Fall -1 Other -I Retardant/Accelerator(name) .� C <br /> PEDESTAL Installed By Driller Pump Contractor _1 Other E <br /> Concrete Pedestal 1Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe t.l.. 0 <br /> PUMP Submersible Turbine '1 Other HP Pump Set It Standing Water Level <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 ACTIV WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS <br /> COMP <br /> ION LAWS. <br /> MINIM UR A C ICE REQUIRED FOR INSPEClT'IO/)N/Ar PLEASE CALL(209)953-7697 <br /> 53-769{7� <br /> SIGNED TITLE I�C• DATE L - V `� ~ <br /> ED <br /> EALD-, <br /> IF I F <br /> 'AYMENT <br /> III YL 11 F RED'ENED <br /> C Z 3 2014 <br /> "ROhM COUNTY <br /> LTH�Fa4aKTAL <br /> IAENI <br /> DEPARTMENT USE ONLY <br /> Application Accepted By 'v' /V�//� Date Area X03 Employee ID# <br /> Grout Inspection By Date I_ SPECIAL Well Permit <br /> Pump Inspection By Date f WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/-Codes <br /> ermit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> -- <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4130/12 <br />