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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-RFFtINnARl F PFRMIT CAI I /2nQ1 Q5S-79Q7 PnR INSDFC17nNB FYPIRFR I VFAR conu dere Ieenen <br />JOB ADDRESS1 <br />( CITY/ZIP �j '4( �u <br />CROSS STREET � <br />[iVr'��% V PARCEL SIZE LAND USE APPLICATION # <br />�CX� <br />C� A �APPN�I- /j <br />OWNERNAME 1 <br />/�,y V L l PHONE(qrh)51�J — <br />oLcz <br />fI/U� <br />/ <br />OWNER ADDRESS 1 �.0 <br />CITYISTATE/ZIP 071- 6 <br />/��I yy� <br />CONTRACTOR � �V�Jry4) 1{.�1 Vi i <br />(j yl`• <br />/� �7 <br />l l r -{� J�[-t„,tIV V-' (I V (.. ✓ <br />1PHOO7NE <br />��� <br />CONTRACTOR ADDRESS '�j (�� <br />��o <br />, <br />rLj �.(� I CITY/STATEIZIPV 'n� v�I�+ ` Oo C \ ' L V 1(// 63 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />�� �/-V <br />LICENSE C-57 C-61 <br />-09 Other NUMBER V� EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ <br />INTENDED USE DomesticlPrivate X <br />Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: <br />water system Name on a ame or ne Num0er <br />TYPE OF WORK New Well I Replacement Well - Well Alteration/Modification I Other <br />Monitoring Well s) <br /># of borings <br /># of wells Soil Boring(s) i , Geotechnical <br />I Out -Of -Service Well <br />Out -Of -Service Well Renewal i i Cross -Connection Repair <br />I <br />New Pump i Pump Replacement Pump Repair Raise Well Casin <br />WELL CONSTRUCTION <br />Drilling Method/ Mud Rotary Air <br />r ' y I 1 Auger ! Cable Tool i Push Point i i Other <br />Proposed Well Depth <br />Excavation 2q in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />".I Conductor Casing <br />in diameter / Conducttoor`Csing Depth fl <br />Well Casing DiameterLl Thickness/Gauge/ASTM Sched - Dt "teel Plastic ! ! Stainless Steel Other <br />rout Seal Depth Z 2i�f� fl <br />i Neat Cement (94 /b bag75r10 gal wate/ Sand Cement 3 SQ C sack m/xl7 gal water <br />i Bentonite (20% solids) ! i Other <br />Grout Placement Method umped <br />Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller <br />! Pump Contractor Other <br />Concrete Pedestal <br />.Dimensions: Width fl Length fl Thick in Christy Box I Stove Pipe <br />PUMP Submersible! Turbine I: Other HP Pump Set fl Standing Water Level fl <br />PE <br />E . <br />1 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 />MI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -- PL CASSE (209) 953-769J7 /L� <br />SIGNED \��i��Ue -� TITLE T lwY �' r �Y A � -l/V► I DATE 010 711 J <br />DEPARTMENT USE ONLY <br />Application Accepted By Date ( Area Employee ID# 1 <br />Grout Inspection By Date fl SPECIAL Well Permit <br />Pump Inspection By Dale 17 WAIVER Received <br />_N <br />D <br />Soil Boring Inspection y Date Constructed Well Depth tt ` <br />COMMENTS )-A�-tt'jaWA- <br />V16 Lt i' <br />PE Sc ReceivedAmount D to Permit/ Invoice# Well 1D# <br />Codes Info B Cash Remitted Service Request # <br />a &.7- <br />1-71h 3 <br />EHD 4306 WELL/PUMPPER <br />4130/12 <br />