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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NOON -REFUNDABLE PERMIT CALL 2,(09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR DATE ISSUED <br />Joe ADDRESS % _ • <br />(F`ROM <br />r !� yCITY21P I 1 U1V? 9J3 <br />/7 fn (�� <br />CROSS STREET_ Re -Y e-IC/y R 0 APN <br />PARCEL SIZE(LAND USE APPLICATION #_ <br />L <br />OWNER NAME S <br />-PARCEL <br />PHONE <br />OWNERADDRESS <br />_ <br />CITYISTATE/ZIP <br />CONTRACTOR Kl.einfelder <br />PHONE 209-948-1345 <br />CONTRACTOR ADDRESS 2001, Arch -Airport Rd. <br />Suite 100 CITY/STATE/ZIP Stockton, Ca. 95206 <br />SUBCONTRACTOR V&W Drilling <br />PHONE 209-469-7700 <br />11 <br />SUBCONTRACTOR ADDRESS -Cci-TJr. <br />/�!Y�1Dti <br />O - <br />3J <br />. (' <br />I-II <br />(;ITy JTATEOP <br />LICENSE C-57 D C-61 D D-09 O Other <br />720904 �� kr Zit ` CjL: <br />NUMBER ExPIRAnoN DATE 4 1.41) 12 1) A <br />GEOGRAPHICAL INFORMATION: Coordinates X YTownahin awn,.e ca...o.,., <br />INTENDED USE D Domestic/Private fl IrdgatlonlAgdcuhural ❑ IndustriDl D WalerOualiry Monitoring 9[Solt Sampling/Chareclerizat(on V <br />D Public nt frwwner; System <br />If dirterenl from Owner. a r ys em ame ---' on ec eme or one um .r <br />LJ well WterauorvmoGIIICarion ❑ Other <br />— <br />11 Monitoring Wells) # of Wells U Soil Borin9(s) a botys � Geotechnical <br />D Out-Of-Servico Well n Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />U New Pump 11 Pump Replacement 0 Pump Repair n Raise Well Caslrtn <br />Drilling Method I1 Mud Rotary I Air Rotary k( Auger I; Cable Tool f I Push Point 11 Other <br />Proposed Well Depth ZS , ft Excavation in diameter I I Cpen Bottom r1 Gravel Pack/Gravel Size in diameter <br />r1 Conductor Casing In diameter / Conductor Casing Depth _ft <br />Well Casing Diarneler_._ in Thickness/Gauge/ASTMSched 11 Steel f Plastc L Stainless Steel II Other_ <br />Grout Seal Depth__ _ ft Y Neat Cement (94 lb 689/5-10 gal water) 1 Sand Cement __sack mix17 gal water <br />( i Bentonite (20% solids) U Other <br />Grout Placement Method D( Pumped I I Free Fall IJ Other LI Retardant/Accelerator name <br />IPEDESTAL Installed By 0 Driller I.I Pump Contractor I I Other <br />CI Concrete Pedestal LIDlmenslons: Width It Lenglh h Thick in fJ Christy Box t7 Stove Pipe <br />uMP <br />1; SUbmar®iblaiJ Turbine LI Other HP PUMP Set ft Standing Water Level rt <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 FO I SP CTIONNS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE Q ` t"i 1 " e -Ir DATE <br />f—T- bbb — <br />PA <br />Application Accepted By <br />Grout Inspection B; <br />Pump Inspection By <br />Sail Boring Inspection By <br />COMMENTS <br />M E NT U E O <br />Date Area Emplo <br />Date SPECIAL e11 Per <br />Date _ ❑ WAIVER ecelved <br />Date Constructed Well Depth <br />A <br />m <br />0 <br />A <br />N <br />ft <br />PE SC <br />Codes Info <br />Received Ch C l Amount <br />El Ceah emitted Date <br />PermW <br />Service tN Invoice 1 # <br />WELL /PUMP PERMIT <br />I <br />h� <br />