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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />Sc Received <br />Info B <br />CALL 209 95�3+-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM(M DATE 15SSUED <br />M <br />y�go <br />�i <br />Z <br />o <br />JOB ADDRESS, -Q-`) <br />i Imo)F1 <br />`2 � l CIFY/ZIP t� <br />/� / � <br />CROSS STREET�L��qq <br />��A/JPN <br />() y r1 a .� o 07 PARCEL SUE <br />LAND USE APPLICATION # <br />IP, <br />k,2— <br />OWNER NAME 1^L'�1//� 4-i <br />tC,3(); <br />t')tl <br />PHONC��(2) <br />OWNER ADDRESS �W�(!V\'�^ <br />CITY/STATE21P ..S&�nn1u? <br />l <br />, <br />CONTRACTOR ! <br />PHONE i)Y T(p <br />CONTRACTOR ADDRESS _ <br />Y CITY/$TATE21P C%' <br />•7�-T S�(/1 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/$TATE/ZIP <br />r <br />LICENSE - C-57 '- C-61 <br />D-09 <br />.` Other' r! NUMBER <br />EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE 7-Domestic/Private Irrigation/Agricultural - Industrial Water Quality Monitoring ; Soil Sam pling/Characterization <br />Public Water System <br />If different from Ownec Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well IWell Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Bnrino(s) If of bonngs Geotechnical # of bonngs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />ttalse well <br />)rilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />proposed Well Depth ft 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 Schad Steel Plastic Stainless Steel ' Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement Sack mix/7 gal water <br />Bentonite (20% solids) Other <br />3rout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By (-Driller Pump Contractor Other <br />Concrete Pedestal -Dimensions: Width ft Length It Thick in Christy Box Stove Pipe <br />PUMP ji�­3ubmersible 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 />CE NOTICE REQUIRED FOR/INSPECTIONS - PLEASE CALL (2l <br />�— TITLE (/) // 7�/� DATE <br />DEPARTMENT USE ONLY <br />kApplication Accepted By�� l �� Date L �'<<` Area / Employee ID# <br />Grout Inspection By L Date j ❑ SPECIAL Well Permit <br />Pump Inspection By l kr�G 5� .E> t �y_l Date 41 riI'1 J 0 O WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />H <br />In <br />Ac MINT <br />E/ AFD <br />0 8 ?020 <br />>NMElvouNTy <br />Epq R 7'4NENT <br />PE <br />Codes <br />Codes <br />Sc Received <br />Info B <br />ash <br />Amount Date <br />Remitted <br />Pa -'V <br /># Well ID# <br />Service Re uest # <br />y�go <br />Oma/1216 <br />EHD 43-M <br />4/30/12 <br />WELL /PUMP PERMIT <br />