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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 CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ��1 � 1 (~/t ��� CITYIZIIP�•I , �� �y ��v Z`� <br /> CROSS STREETI)A // APN 0' �- V —0'7"' PARCEL SIZE. `�N�--LAND USE APP�LIICATION# J! �J m <br /> OWNER NAME <br /> GQC / Vj PHONE C�/Or �J <br /> OWNER ADDRESS _ J� CITY/STATE/ZIP <br /> /] 7 l <br /> CONTRACTOR /✓ corwit ns PHONE �% / /� <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR + �f t1, I I - PHONEt Z Z z 2 Z <br /> jug �_ r <br /> SUBCONTRACTOR ADDRESS , /S �.r �5�[� LCIITTY/STAT/EIZIP {�f AlCENSE ;<C-57 AC-61 n D-09 _ Other NUMBv ER EXPIRATION DATE 1 9 Z 5 <br /> Ir <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural 1 1 Industrial L I Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> U Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORKNew Well I I Replacement Well Ll Well Alteration/Modification D Other <br /> I I Monitoring Well(s) #of wells D Soil Boring(s) #of borings I I Geotechnical #of borings <br /> I 1 Out-Of-Service Well U Out-Of-Service Well Renewal D Cross-Connection Repair <br /> )dNew Pump I I Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRU ION <br /> Drilling Method 04Mud Rotary 1 Air Rotary I 1 Auger ❑ Cable Tool ❑ Push Point D Other <br /> Proposed Well Depth -d 76 ft Excavation l?_ in diameter n Open Bottom 1XGravel Pack/Gravel Size in diameter <br /> I Conductor Casing- in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ZZO I-) Steel /N Plastic I Stainless Steel Other <br /> Grout Seal Deptw�_r---27�h ft a Neat Cement(94lbbag/5-10 gal wat r) U, Sand Cement sack mix/7 gal water <br /> `bb� <br /> Bentonite(20%solids) ,tYf$rYnfl ,Q'V on, qt-LCL-I- SQL <br /> Grout Placement Method n Pumped [I Free Fall LI Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 'y Pump Contractor 1 Other, <br /> 11 Concrete Pedestal DimLfnsions:Width ft Length ft Thick in I Christy Box 1 i Stove Pipe <br /> PUMP 1 Subrnersiblel 1 Turbine rl 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 4 HOUR ADVANCE NOTICE REQUIRED FOR I P/E�CT/I/ONS - PLEASE CALL (209) 9/53-7 97 <br /> SIGNED TITLE rCJ/L{�� DATE Y evl <br /> J <br /> 11—r A <br /> if -Lill <br /> 3 <br /> L. <br /> -- N <br /> I <br /> D E P A R T M E N T U S E O N L Y ^^ <br /> Application Accepted BY <br /> Date Z 3 `� Area D 0 0 Employee ID# vim <br /> Grout Inspecti - Date SPECIAL Well Permit <br /> Pump Inspectio B Date -I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS D <br /> PE Sc Received he Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B sh Remitted Service Request# <br /> 366 I vo <br /> 41 lb p SD �l � �3- <br /> EHD 43-06 / w' �C,vc�'.v .L��✓� v� WELL/PUMP PERMIT <br /> 413(111 J <br />