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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS JC_ 4 CI7Y/LP �) � �. �S.,y / D <br /> CROSS STREET L<�1/{�(� '/ -['' '�" ( APN 7 — ��- FEELL�-SIZE LAIiD 1J5�A�P #r I m <br /> OWNER NAME /r)C4 I1 l) V2 rI 6 C ' / PHON�7w"'PLICATION\ v C <br /> OWNER ADDRESS / l �i"� J CITY/STATEIZIP / t G �L( V r <br /> � / <br /> CONTRACTOR R 1 L Ci I C'� ;/�-yI r- 1 I I C' Ln_(� ,,IP``��HO <br /> CONTRACTOR ADDRESS / CITYISTATEIZIP Z �j�, <br /> i <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/LP <br /> LICENSE C-57 1 C-61 D-09 Other NUMBER I '-7l. EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE omesbdPrivale Irrigation/Agricullural Industrial Water Quality Monitoring Soil Sampling/Characlenzation <br /> Public Water Syslcin <br /> Y AiHerr t'rnm Owner. a.r,y,e ame contart 1-mr,or —r. um cr <br /> jME OF WORK New Well Replacement Well Well Allerahon/Modificalion Other <br /> MonitoringWell(s) Itofwells SoilBoring(s) #of borings Geotechnical iF cif Uonrxls <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ud Rota Air Rotary Auger able Tool Push Punt Other <br /> Proposed Well Depth'3(')0 It Excavation�in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth--- It <br /> Well Casing Diameter �,^ in Thickness'GaugeiASTM Sched Steel ix Stainless Steel Other <br /> Grout Seal Depth 0gd'_ft Neat Come t(941b ag//51-10 gal water)- Sand rent sack mix/7 gal water <br /> Benlonite(20%solids) Other er-j �� <br /> Grout Placement Method Pumped Free Fall Other R ardanl/Accelerator(name) <br /> PEDESTAL Installed By DnIMr Pump Contractor Other <br /> Concrete Pedestal Dimensions.Width tt Length It Thick in Christy Box Stove Pipe <br /> ------------ <br /> PUMP Submersible Turbine Other HP Pump Set it Standing Water Level ft <br /> 1 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. 1 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 C PENSATION LAWS, <br /> 1 UM Hou f�pVANCE,II(OTICE REQ ED F N C S- L CALL(209)953-769/7+ <br /> SIGNED LE DATE u <br /> r 0 <br /> rn <br /> AA- <br /> v -+ <br /> DEPARTMENT USE ONLY <br /> pL <br /> Application Accepted By--� Date 7-1 t<2&21!r- Area Employee ID# <br /> Grout Inspection By�� Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By /�pir at Conjtrueted WellPepth ft <br /> COMMEN'S d r t Q41 lz+4t? .Sp �Jt f 12�/'� <br /> or- <br /> -60 rej74?,'A.1C � <br /> PE SC Received Check#/ Amount PerrniU <br /> Codes Into B Cash Remitted Date Service Request# Invoice# Well ID1f <br /> y i8a C� o vas 2 23\5 <br /> 34 <br /> EI043oc e /-�i r� e ccela <br /> 4%3Un2 <br />