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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 /A\ CALL 209 953-7/6697 FOR <br />RIINSPECTIONS <br />r1lJ j EXPIRES 1 YEAR FROM <br />�/DATE ISSUED <br />JOB ADDRESS L A Al �V C-551 -✓ IV c",,V Lc)pi I 152 0 <br />CROSS STREET W 1/dy. 1 -Lo APN �� PARCEL SIZE (' LAND USE <br />APPLICATION #� �J <br />OWNER NAME F, e PHONE <br />OWNER <br />OWNER ADDRESS "i-y"i`/ W 1 �1�1 , CITY/STATE/ZIP ✓7(JIB► / Cf� ✓Z <br />It. <br />CONTRACTOR <br />CONTRACTOR ADDF <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE j(C-57 __ C-61 <br />CITY/STATE/ZIP <br />NUMBER `JJ 1(4IN <br />PHONE <br />EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: COO ria ~i Y Township Range Section <br />INTENDED USE Domestic/Privateirf industrial .. Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System ame Gontact Name or Phone Number <br />TYPE OF WORK ')< New Well Replacement Well Well Alteration/Modification Other At40M LA <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal 1 Cross -Connection Repair <br />vven case <br /># of borings <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth L.W ft Excavation bog in diameter . Open Bottom _ Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter -Z—in Thickness/Gauge/ASTM Sched . Steel )( Plastic Stainless Steel Other <br />Grout Seal Depth So ft Neat Cement (94 lb bag/5-10 gal water) )(Sand Cement kO a-_3 sack mix/7 gal water <br />._ Bentonite (20% solids) Other <br />Grout Placement Method ')( Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller 1 Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Lenoth ft Thick in Christy Box Stove Pine <br />T <br />D <br />v <br />v <br />m <br />m <br />Vl <br />PUMP Submersible ` Turbine A Other N JA HP Pump Set --------- V PjjCnW#!j1jj,1 ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL -,-D() IN AC CE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CE�fFTI�� LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AN M E WITH ALL <br />WORKERS SATION LAWS. <br />I UM 24 VHU7rA CE OTICE R UIRED FOR NSPECTIONS - PLEASE CALL (209) 953-7 <br />SIGNED TITL�- ��� DATE D <br />LLitr <br />'y;7 <br />' <br />0 :COUNTY <br />DEPARTMENT USE ONLY <br />Application Accepted By L � Date JJZ4,11 f Area l f Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />I# <br />MC <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />