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ft Thick in _ Christy Box _ Stove Pipe <br />EngEN, Installed By Driller ), Pump Contractor Other <br />_ Concrete Pedestal _ Dimensions: VVidth ft Length <br />-•leff‘ <br />0-2 igr cs f <br />7 ' 10 C caj <br />I 0 CIA. <br />3c-9)cliP <br />50 (1,1 46,1 <br />gq5 -(6 0 Coairg. <br />1 6O -(9 9r; <br />i ct-20 <br />105 -la (10(1 <br />2-17 -Zt 0 Coz.vv <br />CrAidi Cottviti( <br />430112 <br /> <br />ES eevdCek*Aon emt <br /> <br />oe noB ahRmte aeSrieR us noc*Wl D <br /> <br />31 OZj`11 a-+92°i 1 o4642 <br />on... L. <br />WELL /PUMP PERMIT . /2396 <br />11) <br />As - Area 3 }Mc: 11 4eet:' Employee IDS <br />"Ilr.) I 2 SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 488-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS a..-a-ca .5 hie R.- ft a ct-t.1 Crrr/Zip rtk.itt.c...0% 9S. 3 A <br />In <br />CONTRACTOR %.wIF,rt ex- Dr: (I rN/nC. <br />CONTRACTOR ADDRESS 3 O0 S . 1<;1 vt -g-01 <br />OWNER ADDRESS <br />CROSS STREET 006 s • 0 dt Q r. APN I 9 g .1° S PARCEL SIZE 9 LAND USE APPUCATION 7 C : Pr es Ter vs-T- PHONE .1s6 s631: 000 <br />PHONE s ris" <br />OWNER NAME <br />° ST D <br />CITY/STATFJZJP -TV r ° CaL 153 •Erc.•1 <br />CITY/STA TEIZIP <br />.443 <br /> CITY/STATE/ZIP <br />LICENSE V‹.--57 _ C-61 0-09 Other NUMBER 14 19 t e‘ <br />SUBCONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />EXPIRATION DATE s ;L. \ <br />PHONE <br /> <br />GEOGRAPHICAL INFORMATION: Coordinates X 371l icHS y al• 0 43 Township Range Section <br />Domestic/Private Irrigation/Agricultural - Industrial <br />_ Public Water System <br />If efferent from Owner <br />INTENDED liSt <br />Wider SySteM Name <br />TYPE OF WORK .New Well _. Replacement Well Well Alteration/Modification _ Other <br />' Monitoring Well(s) *of wells - Soil Boring(s)Geolechnical <br />8 of Oonop5 <br />Out-Of-Service Well - Out-Of-Service Well Renewal Cross-Connection Repair New Pump :._ Pump Replacement _ Pump Repair Rase Well Casing WELL CONSTRUCTION <br />Drilling Method A- Mud Rotary _ Air Rotary Auger _ Cable Tool Push Point <br />Proposed Well Depth .3•--°•Ci ti Excavation -.4 1. "(:) in diameter 7 Open Bottom Other <br /> <br />-Gravel Pack/Gravel Size *Co in diameter _ Conductor Casing in diameter / Conductor Casing Depth ft <br /> <br />Well Casing Diameter j,in Thickness/Gauge/ASTM Schad ..-1 L Steel A-Plastic 7 Stainless Steel Other Grout Seal Depth SO ft - Neat Cement (94 lb bag15-10 gal watef) ).Sand Cement 10 . 1 <br />- Bentonite (20% solids) Other <br />Grout Placement Method N,. Pumped _ Free Fall - Other - Retardant / Accelerator (name) <br />sack mbt17 gal water <br />Eute <br />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 UCENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPUANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINI UM24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Date it <br />Date <br />ate <br />APP9Cation Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS W . t <br />Submersible.. Turbine ._ Other HP Pump Set ft Standing Water Level <br />SIGNED t T TLE rri DATE <br />or borings <br />Water Quality Monitoring .7 Soil Sampling/Characterization <br />COMM Name Or NuMOOr <br />DEPARTMENT USE ONLY