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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 - (209)468-3420 <br /> NONREFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Q /� T � <br /> JOB ADDRESS � 6 0/ 1 X16 /Q CITY/ZIP t 1 CL�,r 9�� m <br /> D <br /> 0 <br /> CROSS STREET C APN7? —,/PARCEL SIZE LAND USE APPLICATION# m <br /> OWNER NAME `'�/1.Y`` �C�GI'4�CA� PHONEJ�� /L��S <br /> OWNER ADDRESS Muc;. �le li k n5- L S �Y- CITY/STATE/ZIP a�QS�, c j7j 9s-3sk S.A <br /> CONTRACTOR Y , ,PHONE _ 3 6 7,Q�8b J !� <br /> CONTRACTOR ADDRESS Y CITY/STATERIP �14 121�kr* If G gS � <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS Az'Za= CITYYy/��STATE/ZIP <br /> LICENSE C-57 )eC-61 D-09 Other NUMBER C/ EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township 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 Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well C Replacement Well - Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells -1 Soil Boring(s) #of borings Geotechnical #of borings <br /> E Out-Of-Service Well -i Out-Of-Service Well Renewal E Cross-Connection Repair <br /> New Pump L Pump Replacement L Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary C Air Rotary E. Auger ❑ Cable Tool - Push Point - Other RV � <br /> � r <br /> Proposed Well Depth!,jlO J`S ft Excavation << in diameter Open Bottom XGravel Pack/Gravel Size_ in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter j,_in Thickness/Gauge/ASTM Sched ASo eY,Steel -- Plastic Stainless Steel ❑ Other <br /> Grout Seal Depth ) 1C?Uft C Neat Cement(94 Ib bag/5-10 gal water) ,Sand Cement Sack•mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method XPumped - 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ,s <br /> SIGNED TITLE IZ.;e DATE / <br /> UAI It U IT] 14 Pull <br /> t <br /> EU 11 tip PIP <br /> N <br /> EVIG qlV ETA H T <br /> R TSRICS <br /> U c AL <br /> (FI DE AR = <br /> 4 DEPARTMENT USE ONLY <br /> Application Accepted By ✓1.�-v Date )T-11 It / Area 0 5- �1 `11 Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Const ucted Well Depth ft <br /> COMMENTS ".Sw i'� i'�v � l'(� S Szs .kc S &r1�0�- � <br /> PE Sc Received he Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> -5 61 Igo60 3Al I j <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 9/28/07 <br />