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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE <br /> PERMIT �/1 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ✓1 5 7 C, FLA VI r.M m <br /> o n R p C /LP .A(C)/-1 e0 r � J .� ��•� <br /> IJt D <br /> CROSSSTREET C 011 1(f 1� 7 APNIVI-Q1k-!�S <br /> /��1 PARCEL SIZE 5 LAND USE APPl10AT10NC�A G(� A <br /> OWNER NAME �"), 1 4f L If 1 1 11,,V�'1 PHONE,f,�J _,J/ JS(,t ICS) 1 1 y <br /> OWNER ADDRESS �\ I/ / fi I (.�'f C � '� CITY/STATE/ZIP M tt Y)-Ce C,TA I /:'"� _I; ,J X <br /> CONTRACTOR \�I� I� � ir 11 ')'i PHONE C; �1�, -/ 7-7a <br /> CONTRACTOR ADDRESS P- G ��zZ V G X /�1 CITY/STATE/DP I-�/ .ny <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CCrry/STAATE//jLZP <br /> �'� <br /> LICENSE C-57 C-61 _'D-09 _ Other NUMBER 613 ExPIRATIoN DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range Section_ <br /> INTENDED USE ;?`,Domestic/Private '-Imgabon/Agricultural - Industrial Water Quality Monitoring ,Soil Sampling/Characterization <br /> Public Water System <br /> Ir d,11—M from Owner w.t.,S"t— nmo Contad N-or Phone Number <br /> TYPE OF WORK New Well Replacement Well -Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells -Soil Bonng(s) iolbonrga - Geotechnical aof oo g, <br /> Out-Of-Service Well Out-Of-Service Well Renewal F Cross-Connection Repair <br /> New Pump 6 Pump Replacement r Pump Repair L Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool - Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom �><Gravel Pack/Gravel SizJ/l - in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_(L-, in Thickness/Gauge/ASTM Sched -?c0 1Steel .Plastic C Stainless Steel Other <br /> Grout Seal Depth I CG A Neat Cement(94 Ib bag/5-70 gal water) KSand Cement I C ,� sack mixl7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped '_,Free Fall Other -i Retardant/Accelerator(name) <br /> PEDESTAL Installed By _ Driller L:Pump Contractor Other <br /> Concrete Pedestal-Dimensions:Width r ft Length_—ft Thick in "Christy Box Stove Pipe <br /> PUMP Submersible Turbine r Other HP___S_ Pump Set ft Standing Water Level <br /> I HEREBY CERTIFY THAT 1 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Qi C C CS ,CIC.vl'-1•- DATE <br /> i <br /> 14, <br /> qw p <br /> k 77 <br /> RF yMF <br /> --r,I -i <br /> J �or <br /> U� <br /> 0 <br /> oq Q� 8 ��21 <br /> Ty�� Cob <br /> t <br /> MFNT <br /> D.E <br /> Ay M E N T U E ,INNLY / <br /> Application Accepted By ate V - Area <br /> -,GEmployee ID# �� Z <br /> Grout Inspection By Date ?i �� ] PECI L Well Permit <br /> Pump Inspection By <br /> 6 Z�J WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth O ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount PenniU <br /> Codes Info B Date Cash Remitted Seryice Re uest# Invoice# WeIIID# <br /> 446 Alto ?S ' <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4130112 <br />