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k WELL/PUIVIP4YEAMIT �et� �,�;ON C�'35Zf13'f f�'w <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKT w468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> m <br /> m <br /> JOB ADDRESS G ' I r` CITY/ZIP D <br /> CROSS STREET r APN y y PARCEL SIZE-xqJ✓AAND USE APPLICATION# m <br /> F to <br /> OWNER NAME CA a l ^ PHONE <br /> OWNER ADDRESS 1 1 CITY/STATE/ZIP �� <br /> L` � / ' <br /> CONTRACTOR ' r�' PHONE �1 ? <br /> CONTRACTOR ADDLIU <br /> RESS 1� CITY/STATE/ZIP �cev�j* <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE(ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER-IN( VV\11 4 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water S Cc? Phone Number <br /> h IT <br /> R M <br /> TYPE OF WORK New Well ❑ Replacement Well El era"o A ,.i tin r <br /> ❑ Monitoring Well(s) #of wells ,;oil B ring(s), #pofpboyringsp� 4t, chnical �n <br /> ❑ Out-Of-Service Well ❑ Out-O�dr ni 1 e �l� �` �`n3ti � tiY3A epair R CD <br /> ❑ New Pump ❑ Pump Replacement ❑ Pu ai C <br /> WELL CONSTRUCTIOW "I�.� { n APR 2015 <br /> t3fb► b���I Pr11,, ,{� ��� S10 . <br /> Drilling Method' Mud Rotar, ❑ Air Rotary ❑ Auge• � a T CS'F° tArIT 'tr' ?her <br /> Proposed Well Depth _ft Excavation . .�D _-in diameter ❑ Open Bottom ❑ Gravel Pack/Grav SG f dl�I7er <br /> [Iel Conductor Casing in diameter / Conductor Casing Depth ft el t SPAR <br /> Well Casing Diameter],in Thicknes auge/ASTM Sched �7.0 ❑ Steel Plastic ❑ Stainless Steel Other <br /> Grout Seal Depth It Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method El Pumped Li Free Fall Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ^Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Ditthensions:Width ft Length ft 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 VE PRE ED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORD hfANC ST E L WS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIV WITH T E CgLIFORtOTICE <br /> A CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSA ION LAW . <br /> MI MU 2 UR D A CE REQUIRED F INSPE /T�ION -PLEASE CALL(209)9 3-7 97__ <br /> SIGNED / TITLE l DATE LA <br /> «. e <br /> r., tivn�Y - .r., <br /> 4�� <br /> 1+ ( 'j{,� ,.7 b nMN s - :+tp2"(iF}( '�✓ �[' a .'t <br /> •l 1 ��S[ll.v��. t1{�I�f � b M1 1 1n4 91~er,'�•�ry1 b— � <br /> , 1 ty{"yC-0���, �Ilfr ,,.l..�e. wsa,• b. 'Z ; •Y <br /> I" r���x w.�lr.,b 1► �� O <br /> DEPARTMENT USE ONLY <br /> Application Accepted By - Date 17 Area L Employee ID# �=5 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received eck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Remitted Service Request# <br /> WELL/PUMP PERMIT <br /> EHD 43-06 <br /> 4130/12 <br />