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P` LV <br />E"i <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 96205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT . CALL 209 953-7697 FOR INSPECTIONS ���E�--XPIRES I YEAR FROM DATE ISSUED <br />JOB ADDRESS �`)0060, Ce a' r A �I'e.. {.T(CLC ti C ✓7 �S3o CITY/L 1P / / ae r� <br />CROSS STREET C-15( () Cl) (// VC) APN )J J 11 PARCEL SIZE�N• L1 LAND USE AAP�P�LIIfCATION # <br />OWNER NAME _ 1 Vh n(� f \ISS 1 }/��'PHONE .-" / Y32-3 0 7 7 <br />OWNER ADDRESS P` b. Boy( O� CITY/STATE/ZIP / `I r/%n r-4 U366 <br />CONTRACTOR L c..[/ -!�f O• / (� /i' PNnMP /n /.' 7 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR ADORES <br />LICENSE _ 57 <br />u G-61 a D-09 <br />� Other <br />CIN/STATE/LP <br />PHONE <br />CIITYY//S(TTAATEEIZ PP , !y <br />-(LLI1(' LrX.RATION DATE — l <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE ❑ Domestic/Private • Irrigation/Agricukurai 6 Industrial ❑ Water Quality Monitoring n Soil Sampling/Characterization <br />U Public Water System <br />If different bom Owner. water em me o a Name or one Um <br />TYPE OF WORK X New Well L Replacement Well a Well Alteration/Modification Other <br />n Monitoring Wells) # of wells n Soil Boring(s) sof bonngs C Geotechnical—T:1 <br />i Out -Of -Service Well Out -Of -Service Well Renewal n. Cross -Connection Repair <br />New Pump C Pump Replacement Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />% <br />Drilling Method 4e4lud Rotary t. Air Rotary i Auger , a /Cable Tool i Push Point a Other <br />Proposed Well Depth -1— ft Excavation -.21 '7 in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br />L, ConductOr asing in diameter 177 Con ctor Ca 'n Depth —ft <br />Well Casing Diameter in Thickne Gauge/ASTM Sched Steel .�Ptastic i Stainless Steel Other <br />Grout Seal Depth_ �ft ❑Neat Cement (94 /b ba_W5-10 gal watJer) nd Cement ck mb 7 gal Water <br />n Bentonite (20° ids) n Other <br />Grout Placement Method umped ❑ Free Fall ❑ Other ❑Retardant /Accelerator (name) <br />PEDESTAL Installed By :1 Driller c Pump Contractor [I Other <br />U Concrete Pedestal L Dimensions: Width ft Length it Thick in u Christy Box I. Stove Pipe <br />PUMP u Submersible Turbine a Other HP_ Pump Set ft Standing Water Level it <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 />NOTICE REQUIRED FOR }IG PECT ONS - PLEASE CALL (209) <br />TITLE f /�I�- DATE <br />DEPARTMENT USE,ONLY <br />Application Accepted By Date l <br />Grout Inspection By Date <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Date <br />Area D 1 l / Employee ID# t o 5106-U 0�> <br />❑ SPECIAL Well Permit <br />0 WAIVER Received <br />Constructed Well Depth ft <br />EHD 43-06 <br />4130/12 <br />WELL /PUMP PERMIT <br />