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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 488-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 95133--7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS I R -q'4 <br />1�`, l <br />1 V - "\j % � V • 1z CrTY/L` kAP -1 1 l J :� 1 <br />CROSS STREET ffr A 1 <br />— <br />APN OF / PARCEL SIZE LAND USE A`PPPUCA71ON # <br />OWNER NAME h 4 <br />/-Z� <br />L. ci h e. t s 1 J Kb4 PHONE J � - 313 8 <br />�-Y 1 <br />/c <br />OWNER ADDRESS SA AA f_ <br />Cm/STATEMP <br />CONTRACTOR -O <br />%�JQ <br />` 1 T PHONE -I►� / 1 <br />CONTRACTOR ADDRESS 1_ <br />(/ <br />9 L3 <br />� 4' CRY/STATEMP CA' ` ) CA 7 <br />SUBCONTRACTOR <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE AC -57 AC -61 <br />_ D-09 :. Other NUMBER O EXPIRATION DATE <br />GEOGRAPHCALINFORMAT1oN: Coordinates X Y Township_ Rangs Section_ <br />INTENDED USE - DomesficcJPrivate C Irrigation/Agricultural =. Industrial Water Quality Monitoring Sod Sampling/Characterization <br />Public Water System <br />If ditlererd from Ownen water system Name Name or PrionS NUMM <br />TYPE OF WORK New Well Replacement Well - Well AlteratioNModlfKation " Other <br />Monitoring Wel(s) # of wells Soil Boring(s) a of boMea Geotechnical <br />Out -0f -Service Wed - Out -Of -Service Well Renewal � Cros"onnectlon Repair <br />s of bodrgs <br />filling Method Mud Rotary 7 Air Rotary Auger - Cable Tool Push Point - Other <br />vposed Well Depth R Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thidmess/Gauge/ASTM Schad Steel Plastic Stainless Steel :- Other <br />Grout Seal Depth_ft Neat Cement (941b bWS-10 gal water) Sand Cement sack mW7 gel water <br />Bentonite (20% solids) . i Other <br />rout Placement Method Pumped _ Free Fall J Other Retardant / Accelerator (name) <br />'DESTAL Installed By -. Driller i Pump Contractor - Other <br />Concrete Pedestal ' Dimensions: WiM _ _ It Length ft Thick in Christy Box - Stove Pipe <br />P^UMP Submersible" Turbine r Other HP _L -/ r:L Pump Set_ V_-? R Standing Water Level --I%-) tt <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 />MINIMUM <br />224 H yjWR ADVANCE <br />..NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 4 <br />SIGNED �►'iSf y �+`r� TxTLE CC !? Ye—S I'AC "A DATE I 1 <br />- a <br />EP RTMENT US NIL <br />Application Accepted By Date Area `" 1 Employee ID# &4—� <br />Grout Inspection By Dale El SPECIAL Well Permit <br />Pump Inspection By t Date J WAIVER Received <br />Soil Boring Inspection By Date Constructed Web Depth ft <br />COMMENTS <br />PE SCReceived Check#/ <br />Codes Info B Cash <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Request # <br />o!i-o A <br />8 P 37 <br />EHD 12 �l /j/� MYELL (PUMP <br />,Sens F'EHMI r <br />, 3 _/ <br />