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' e ' <br />per <br />—e r" <br />ast(1 is <br />d13 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />DABLE PERMIT CALL (209) 953-lb9/ <br />JOB ADDRESS -', <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR ry <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS _ <br />LICENSE C-57 D C-61 <br />CITYiZ1Pa <br />/ �I��DON • <br />PARCEL SIZE . 0' 'LAND USE , PPLICATION # <br />PHONNE111`9 /^/ �`r� <br />- CtTYISTATFJZIP A"N,—�a �(3�0 <br />61 <br />PHONE //r 1 � 127 <br />CITY/STATEILP ►o a 53� <br />PHONE <br />CITYISTATE/ZIP <br />D D-09 C. Other NUMBER v EXPIRATION DATE ✓ �� <br />DOMESTIC W�ELLLING: ❑Gen:1(1(neral/COhtOrrn B3Ct8rla (4391) L UIDfOR10CnlOroplopane ttioa</ �ioc�1�.,INTENDEUSesiic/Privaligation/Agricultural -1 Industrial ❑ Water Quality Monitoring C Soil Sampling/Characterizationlic Water Systerrr Contact Name or Phone Number <br />TE µ(A If different from Owner: Water System Name <br />TYP F WORK ew Well C Replacement Well U Well Alteration/Modification ❑ Other Ir of borings <br />Y of borings n ro.,Iorhniral <br />,I Monitoring Wells) x ui wena <br />n Out -Of -Service Well D Out -Of -Service Well Renewal D Cross -Connection Repair <br />C New Pump I Pum Re lacement ❑ Pimnn Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method tud Rotary C Air Rotary C Auger !ICable Tool -. Push Point Cl Other <br />Proposed Well Depth Excavation _ in diameter Ci Open Bottom D Gravel Pack/Gravel Size in diameter <br />C Conducto Casing in diameter I Conductor Casing Depth v ft <br />Well Casing Diameter. ins/w.TThickness/Gauge/ASTM Sched �— C Steel Plastic Cl Stainless Steel ❑ Other <br />Grout Soal Depth- 1 ft D Neat Cement (94 Ib bag/5-f0 gal water) ❑ Sand Cement____ sack mix/7 gal water <br />BeNonite (20 % solids) ❑Other <br />Grout Placemen ethod Pumped C Free Fall C Other ;] Retardant / Accelerator (name) <br />PEDESTAL Installed By '.] Driller C: Pump Contractor -. Other <br />5 Concrete Pedestal DDimensions: Width H Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP 7 SubmersibleiJ Turbine D Other HP Pump Set ft Standing Water Level tt <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 />UR ADVANCE NOTIC UIRED FOR IIINISv/PEC�(TII�O� NS{A�-�QPLEASE CALL (209) 953--77697 <br />SIGNED_ / TITLE Y1 IIw�II/1��U1 ` DATE _n2-7 7,1 <br />DEPARTMENT USE f0NLY <br />a c> A (�, <br />Application Accepted By Date lr ✓�' Areaj/ / / Employee ID# <br />Grout Inspection By ate `0 I �(, SJ I �1 17Z. ` 0 TSPECIAL —Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Sail Boning I pect�on Py Date Constructed Vyell epth ft <br />COMMENTS I M V ft' tr D _ -G P -1r, 117 t. YtOyllz <br />20 r .A tpeie <br />EHD 4}pB S/01/16 ���w /• � � /�7��i�� / WELL /PUMP PERMIT <br />