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IL <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EA&14AMLTON AVENUE-STOCKTON CA 95205-(209)468Jt20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ^C� n1�ly Y Q _ /� /fir r� _N <br /> JOB ADDRESS 300'-6 ' "' `\/ ` �'` CfTY21P ST I� t01\1 / �l J g O 6 <br /> —{p D <br /> ���G S r/ r I-- <br /> CROSS STREET APN I I SD I PARCEL SIZE q5•r LAND USE APPLICATION# A <br /> [� <br /> OWNER NAME 'P0 R 1T <br /> n e S 1 O G It I O N PHONE y <br /> OWNER ADDRESS ��'-L�TD k Al `�t/�)��5+1 rN G I ON S� CITY/STATE/ZIP,�OGk/o/N' Gf4/ <br /> CONTRACTOR � 1 d/ � EEC! (� ^ PHONE '-11 6 -,.fid-43-Floo <br /> CONTRACTOR ADDRE/S+SQ�/�/��{�� A-T"G'R ToN �.J CITY/STATE/ZIP t�O C-k L.L/V.4 6A, q53657 <br /> SUBCONTRACTOR C I SL^.ADC, D RX 1A-f NG PHONE 916 — --10— �-I 6 I'll <br /> SUBCONTRACTOR ADDRESS I o-p S ,13r a ':-�4f'eCA- //CITY/STATE/ZIP RSG H MOND,C-A�RHbOti <br /> 2 <br /> LICENSE A-57 C-61 D-09 Other NUMBER"13�I I O EXPIRATION DATE C- /J Q/ �I-/ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monit ring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name on ac ame or Phore NUMber <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings ✓Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair 1 v <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary -Auger Cable Toot Push Point Other -Hd 110vJ S+em A� <br /> Proposed Well Depth 70—q0 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth it <br /> a <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft /Neat Cement(941b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall ✓Other 7Rz MMI Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length it Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <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 /> MINIMUA�I 4 UR VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953- 697) 6 <br /> SIGNED // TITLE P�� M Jf DATE I <br /> r � <br /> / r �. L <br /> PITJ2 <br /> J M <br /> 0 4- <br /> Q IS4 oar <br /> r <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date ,1-- Area ( Employee ID# <br /> Grout Inspection By Date J PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspe on B QS' u IoS Date 1.7 <br /> tr c d Well Depth k <br /> VIVVi 'I OMMENTS �/U > - Wq A/ r� <br /> PE SC Received Check#7 Amount Date P mit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Servs a Request# <br /> �i isv OW&36C. :? f;,,L iq la EfO-79 <br /> EHD 12 rr N h' _/��j -( �� (�/—7,.,� WELL/PUMP PERMIT <br /> 4HD4 rl f/� I//N` '[P/ 7` LN <br />