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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.1420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> LA <br /> JOB ADDRESS ' , "' -Jo f/ h 50 7 dTY21P Q� v' 1 q3-n <br /> LADD <br /> CROSS STREET �/n/ APNOq-/,,/1 /-Q ARCEELLL SIIZZ,EE LAND USE A LICATION p <br /> OWNER NAME 'C. If S IkIX�e r �hot Tc—,vr/D(/RK►1v LJ �YV e PHONE O / •/ <br /> OWNER ADDRESS <br /> 'Soo ��77,, W �( y Q!.�'Qr� ✓ CITY/STATE21P <br /> CONTRACTOR PHO flele 1) _q 3 <br /> c✓-"` <br /> �1 <br /> CONTRACTOR ADDRESS -gkql( C'0ho 7JJOd� 'ZC1STATE2IP <br /> SUBCONTRACTOR / PHONE ^,F <br /> SUBCONTRACTOR ADDRESS / CITY/STATE/ZIP r\ / 3 Z71' <br /> LICENSE C-57 I C-61 -1 D-09 l Other NUMBER `` " ` t� rte• <br /> J` EXPIRATION DATE � smwar• <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE 1 Domestic/PrivateIrrigation/Agricultural 1 Industrial '1 Water Quality Monitoring I Sod Sampling/Characterization <br /> -1 Public Water Syst CD M <br /> If different from Water System Name L;ontacl arae or one um r CD <br /> TYPEOFWORK New Well -i Replacement Well I Well AlterationtModification -1 Other c -2. <br /> •� rs�wc+J <br /> Monitoring Wells) #of wells I Soil Boring #ofbonngs of borings <br /> Boring(s) I Geotechnical <br /> Out-0f-Service Well 1 Out-Of-Service Well Renewal Cross-Connection Repair ¢ <br /> i New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION e.t <br /> Drilling Method Mud Rotary Air Rotary i Auger, Cable Tool -)Push Point -1 Other Br�.F su <br /> Proposed Well Depth 5-00 ft Excavation 1(4" in diameter �Open Bottom I Gravel Pack/Gravel Size in diameter i <br /> T Conductor Casing / in diameter / Conductor Casing Depth ft Q <br /> Well Casing Diameter 1(9 in Thickness/GaugeIASTM Sched :012.Z 1 -I Steel 'lastic �Stainless Steel -1 Other <br /> Grout Seal Depth_ 0 ft Neat Cement(94 lb bagl5-10 gal water) Sand Cement J IG sack rnix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped -1 Free Fall i Other I Retardant/Accelerator(name) _ <br /> PEDESTAL Installed By 7 Driller *P(PumpContractor 7 Other <br /> i Concrete Pedestal-IDimensions:Widii ft Length ftThick in -1 Christy Box �Stove Pipe <br /> PUMP -I Submersible-1 Turbine -1 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 CALIFO IA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24gHOUR ADVAN TKF D FO INNySPEECT)�O�NS-P-LEASE CALL(209) /53-7766797 <br /> SIGNED 11 yb 1 TITLE �'/l '/ Vrk DATE l—•� l <br /> H ENT <br /> ED <br /> 2014 <br /> llbtj�rH O M o�� <br /> A TMEMT <br /> n i <br /> pts DEPARTMENT USE ONLY _ <br /> Application Accepted By Date 1 AreaEmployee ID# <br /> Grout Inspection By _ Date SACIAL Well Permit <br /> Pump Inspection By Date L WAIVER Received <br /> Soil Boring In ton By Date C d Well Depth ft <br /> COMMENTS Id U I- _ /LPA <br /> PE SC Received ChecW9 Amount PermiU <br /> Date Invoice# Well ID# <br /> Codes Info By Cash Remitted IF Service Re Lest <br /> 4361 Igo4311W Koo-)III'l <br /> EHD43-08 I L QD�9 WELL(PUMP PERMIT <br />