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I D _ WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> CITY/ZIP ���L � 1�z v I m <br /> JOB ADDRESS /�.�Y/yIP�/�l'/�h !/`� �(� /���J m <br /> CROSS STREET /1 APN oI I —//y''�L^�`f' PARCEL SIZEp`�N�-LAND USE APP�LIICATION# m <br /> OWNER NAME <br /> Zd c / Vj PHONE <br /> OWNER ADDRESS J V" /T/ L CITY/STATE/ZIP <br /> CONTRACTOR �DY Nil( n's PHONE <br /> �i <br /> CONTRACTOR ADDRESS /2-0 a,)" ( _ CITY/STATE/ZIP /�/ � 9y Z� <br /> SUBCONTRACTOR Is 1( t✓ PHONE t z z _J Z <br /> SUBCONTRACTOR ADDRESS /'S CITY/STATE/ZIP � <br /> LICENSE C-57 -61 I D-09 Other NUMBER � , �(� EXPIRATION DATE ' I 5 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private CI Irrigation/Agricultural ' i Industrial II Water Quality Monitoring Soil Sampling/Characterization <br /> I I Public Water System <br /> If different from Owner: Water system Name Uontact Name or Phone Number <br /> TYPE OF WORKNew Well LI Replacement Well I I Well Alteration/Modification U Other <br /> I I Monitoring Well(s) #of wells LI Soil Boring(s) #of borings I I Geotechnical #of borings <br /> I i Out-Of-Service Well I Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> dNew Pump Pump Replacement I I Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRU ION <br /> Drilling Method P(Mud Rotary ❑ Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth d 70 ft Excavation /2, in diameter ' Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor CasingIVP in diameter / Conductor Casing Depth ft <br /> Well Casing Diame�tey�r�. in Thickness/Gauge/ASTM Sched zw I Steel Plastic ❑ Stainless Steel Other <br /> Grout Seal ft Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) A r/i �� �,�?il �/ O()I q/-oCII Gt <br /> Grout Placement Method ❑ Pumped I I Fre Fall ❑ Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor I I Other <br /> I1 Concrete Pedestal Dim nsions:Width R Length ft Thick in I Christy Box 0 Stove Pipe <br /> PUMP __ *Submersible[I Turbine I I OtherHP Pump Set ft Standing Water Level ft <br /> — jrI 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 4 HOUR ADVANCE NOTICE REQUIRED FOR I PECT'I/ONS - PLEASE CALL (209) 9/53-7 97 <br /> SIGNED TITLE 11-C/—ry i(/ / DATE S� J <br /> 3 !- <br /> L-- Ilk <br /> I <br /> 3 - _ <br /> i � 9 <br /> /0 / 7- — <br /> 4 ' L C77 <br /> N <br /> D E P A R T M E N T U S E O N L Y <br /> Application Accepted <br /> B Date Z U Area OC ` Employee ID# o <br /> Grout Inspector - Date S14ECIAL Well Permit <br /> Pump Inspectio B Date _i WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS G L ti <br /> A4S <br /> E Sc Received he Amount Date Permit/ Invoice# Well ID# <br /> des Info B sh_ Remitted Service Request# <br /> �6 I go Y,241 - ��`� �� S�°o 6`y q 3a <br /> EHD 43-06 / '�al�-S Z-�- 'GG'l�l.!/. V (/Cl"� WELL/PUMP PERMIT <br /> 4130/12 <br />