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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-1209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 951.7697FOr<ir,Spr- EXEXPPIIRESSIYEAR FROM <br /> �DATE ISSUED <br /> LA <br /> JOS ADDRESS { C» • `vCJ��Gl1 CITYIZip m <br /> CROSS STREET • rAJP�N��r�/�•G. L I PARCEL SIZE LAND USE A�JPPUUCAnoNf�# <br /> OWNER NAME C' i�"�/J 1�,\yy'J'�^ !�I 4{+Jt7 1 1.� PHONE <br /> OWNER ADDRESS YJW (1 <br /> � CITYISYATClZIP -%Cj5;;tM. <br /> CONTRACTOR Vii `&l pum D —DAC.- PHONE(2� 4%r�A1—QLQ,1CJ( <br /> CONTRACTOR ADDRESS CTSTATJZIPSbxkr cf), ozJp <br /> RCL�7 <br /> SUBCONTRACTOR <br /> N Y" / ..................... PHONE <br /> SUBCONTRACTOR ADDRESS ��L CLTYISTATEIZIP fir[ <br /> LICENSE 57 -61 D-09 Other NUMBER�� ExPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE pnleStlr;(PnVate ImIlationJAgncultural '-Industrial Water Quality Monitoring Sail SamplinglCharacterization <br /> Public Water System <br /> I rkffererq from Owner: Water em Name an a -­e­PhuneNumr <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bonng(s) 0 oI borings 0 of nonngsGeotechnical <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum um Re kacement -Pump Repair 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 Size in diameter <br /> Conduc€or Casing in diameter I Conductor Casing Depth tt <br /> Well Casing Diameter_in ThicknesstGaugelASTM Sched ,Steel Plastic Stainless Steel Other <br /> Grout Seal Depth it Neat Cement(94 Ib bag/5-10 gal water) Sand Cement- sack rmxf7 gal water <br /> .. Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant I Accelerator(name) 1 <br /> PEDESTAL Installed By :Onfler Pump Contractor Other \4YJ <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUNT ubmorsible .Turbine OlherHP Pump Set R Standing Water Level R <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 /> 1Vftl+itl U 24 A£IVANCF NOTICE R D FOR INSPECTIONS <br /> SIGNED TITLE ZA~AW DATE ' <br /> PAYMENT <br /> RECEIVED <br /> OCT 17 2011 <br /> SAN <br /> h U_T,i LE F TNENT <br /> LE pN Y <br /> � DEPARTMENT S <br /> U <br /> Application Accept-`4 ". �. Date--�~� AreaC Employee 11. <br /> Grout Inspection .�. Date J PECIAL WBII Permit <br /> Pump Inspection d... �' -+ "" Date 4- "l WAIVER Received <br /> Soil Boring pspectipn BDate Constructed Well Depth It <br /> COMMENTS _. L. _. v,�._ �.,` ,..-_. �., �....., ! � <br /> ��-fir 1 Lr�•� <br /> PE SC ReceivedCheck#L Amount PertniV <br /> Codes Info Cash Remitted pate Service R nest# invoice# Well ION <br /> ifri 4't Dv WELL 1PL1MP PERM?i <br /> grpA/66 <br />