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I2?� WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMI`T� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM tDATE ISSUED <br /> VW <br /> JOB ADDRESS O v oto AV CITY/ZIP <br /> D <br /> CROSS STREET A(LAPN D9 ` -q ),D _PARCEL SIZEOw 1•' N LAND USE APPLICATION# <br /> OWNER NAME �� �,A JI 14M PHONE N <br /> OWNER ADDRESS CITY/STATE/ZIP _ <br /> CONTRACTOR .S PHONE 7 <br /> �� <br /> �2 2S <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP/1iA &/_S- <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIIT'YY/STATE/ZIP _ <br /> LICENSE ,<C-57 C-61 D-09 I Other__ NUMBER G '7 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE omestic/Private I Irrigation/Agricultural I Industrial Water Quality Monitoring U Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well >41eplacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells I Soil Boring(s) n of borings Geotechnical_ If of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal I Cross-Connection Repair <br /> ew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method'<(Nud Rotary Air Rotary f] Auger I I Cable Tool Push Point Other <br /> Proposed Well Depth2--Oro ft Excavation I qL in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conducto Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter `6 in Thickness/Gauge/ASTM Sched-L,4-0 1 I Steel J+�,Plastic Stainless Steel Other <br /> Grout Seal Depth /,at:) It Neat Cement(94 lb bag/5-10 gal water) >&and Cement &•� sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Methode,Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By bie-'Driller Pump Contractor I ' Other <br /> Concrete Pedestal Dimensions:Width t Length ft Thick if in Christy Box Stove Pipe <br /> PUMP ubmersiblei I Turbine 1 1 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 /> MINI � 24 OUR�JDVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br /> SIGNED �A6= TITLE ��/�L DATE <br /> L l 4 <br /> L i <br /> ir <br /> or <br /> �l <br /> L " <br /> Ti Q� <br /> J" <br /> � I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date t ) Area `t Employee ID# � v <br /> Grout Inspection B - Date t�f/y'� ❑ SPECIAL Well Permit <br /> Pump Inspection By t- t Date �1 [� ❑ WAIVER Received <br /> Soil Boring Inspe tion By _ _ Date / Constructed Well Depth ft <br /> COMM NTS_ U( L,; I ��b') t B w (- <br /> 5 - <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By cash Remitted Service Request# <br /> Lo ► > Ll o �q ( �f o0 333 WpOo t037� <br /> 20 0 73 3 743 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />