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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 />NUN -REFUNDABLE PERMIT ■ 1— GALLL/ LUy VDJ-/6`J/ FOR INSPEGTIVN5 tAY1KIZ0 T TtAK I-K^UJ�M LOA It ISSUtU <br />Joe ADDRESS �/` 1� w ) �` —7 CITY/Zip <br />CROSS STREET J V - JI , C I'f 7\ R I' APN U[� / C.i �� PARCEL SIZE �' — ` LAND USE APPLLIICA'TTIION # �7 <br />OWNER NAME (�yT C lY ` ���'J� e�fe PHONE 3 fG 7 I r CIG <br />OWNER ADDRESS `•t 9 V G IZ ?I I\ F-/ Cm/STATE/ZJP Go 1 V 1 CA ci 5 G 3Q <br />CONTRACTOR \It'v-�I (�� p/ r l\ �� n �� /PHONE `� _ 77/9 ^� <br />CONTRACTOR ADDRESS _Y� /� CITYISTATERIP G n I 'i' IC 0 <br />A I J G9 cad <br />SUBCONTRACTOR <br />ADDRESS <br />PHONE <br />CITY/STATE/JP <br />C-61 D D-09 Other NUMBER 3 " EXPIRATION DA <br />MAIM <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE Domestic/Private )Cinigation/Agricultural -1 Industrial J Water Quality Monitoring ❑ Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water m Nam Gontact Name or Phcme um <br />TYPE OF WORK'ANew Well ❑ Replacement Well Well Alteration/Modification I Other <br />_1 Monitoring Well(s) # of wells Soil Boring(s) #of bon's -1 Geotechnical #of borings <br />-i Out -Of -Service Well Out -Of -Service Well Renewal - Cross -Connection Repair <br />V New Pumn I Pump Reolacement Puma Repair a Raise Well Casino <br />filling Method (,Mud Rotary n Air Rotary - Auger i Cable Tool - Push Point i I Other <br />oposed Well Depth -4,4C) ft Excavation IA in diameter i i Open Bottom (Gravel Pack/Gravel Size'/a — in diamete <br />- Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _S_ in Thickness/Gauge/ASTM Schad F' Steel IJ Plastic I I Stainless Steel ❑ Other <br />Grout Seal Depth 56 [_] Neat Cement (94 /b bag/5-10 gal water) ;A Sand Cement sack mix/7 gal wate <br />Bentonite (20% solids) ii Other <br />Ilt,ut Placement MethodV Pumped -: Free Fall 1 Other Retardant / Accelerator (name) <br />Installed By )'Driller i Pump Contractor i Other <br />Concrete Pedestal -Dimensions: Width J ft Length -5 ft Thick in c Christy Box Stove Pipe <br />'PUMP )(Submersible - Turbine Other HP L Pump Set S <dJ it Standing Water Level —j -5V It <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 />N <br />m <br />0 <br />m <br />w <br />Il.— W , r. <br />Z <br />W> ' <br />Ul <br />QW w <br />a� <br />EPARTMENT USE JPNLY <br />Application Accepted By Date Li>? (� Area C t Employee ID# 1: 5-4..0 <br />Grout Inspection By Date ❑ SPECIAL We11 Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />EHD 43-06 WELL /PUMP PERMIT <br />4130112 <br />