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4$WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAINTREET - STOCKTON CA 95202 - (209) 465-3420 <br />NON=REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />'4 (02'j <br />JOB ADDRESS f nom' ° ' �gj 1 `��y�� _ CITY/ZIP <br />CROSS STREET A -(+4(i' 0SA' i"' lAOPN 2-0 `' 40 t)4ARCEL SIZE LAND USE APPLICATION # �y <br />OWNER NAME � G SJ 11� pG�{�i�{ PHONE 2 (` of 9e 2- ` YL 9 dS <br />OWNER ADDRESS 4 X • C H `r2 � Witty CITY/STATE/ZIP (,' �_/ 7 <br />CONTRACTOR 1B P' -N A�' ! /Rf � 1�✓ Q, f l'< x 1 �-T�s hPHONE l Qq-1jl(��' 11-7-7 <br />CONTRACTOR ADDRESS ,3W V `�► �� / ��5 I (V� CITY/STATE/ZIP IJ)jAMU'�L T 4-q*Z. , CA 91-1(45 <br />SUBCONTRACTOR <br />/Gj�L�J {V,"t PHONE j � <br />SUBCONTRACTOR ADDRESS -[ U� V �/ �` CoyV+ k1330 CITY/STATE/ZIP— �crp%r -4 CA 94">� O <br />LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER fq © 23 EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township L S 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 Uontact Name or Phone Number <br />TYPE OF WORK XNew Well ❑ Replacement Well ❑ Well Alteration/Modification `)� Other l-01(-> ts'X 1 FTC. I ION <br />❑ Monitoring Well(s)77 # of wells ii Soil Borings) # of borings ❑ Geotechnical # of borings <br />.❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />LJ New rump a t-ump me iacemeni ❑ t-ump me air ❑ masse vveu cash <br />WELL CONSTRUCTION_] <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary)(Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />la . <br />Proposed Well Depth ctft Excavation In diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel XPlastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft D Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ 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 />INIM^24 HOUR ADVANCE NOTICE REQUIRED <br />IRED FOR INSPECTIONS l <br />• ,i4 TITLE (� RE/6"" M�� DATE S � 2— Ccj <br />DEPARTMENT USE ONLY <br />Application Accepted By Date L <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area �c"aiT�- Employee ID# 3M <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />T <br />m <br />D <br />v <br />v <br />M <br />M <br />Cny <br />-0 <br />h <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />hec <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ Invoice # <br />Service Request # <br />Well ID# <br />-�� <br />N v <br />2 2 <br />`� • W <br />-52 p <br />i <br />EHD 43-06 WELL /PUMP PERMIT <br />8/04/08 <br />