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WELL/PUMP PERMIT <br /> r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTION53p EXPIRES YEAR FROM DATE ISSUED <br /> JOB ADDRESS I V S L4 1r ren 2 C4 CrTY/LP"1()-k C✓',` • / D <br /> CROSS STREET APN 1116 03 D00 0 PARCEL S12E s_3 LAND USE APPLICATION# m <br /> OWNER NAMEI Yl. Il PHONE/� I <br /> OWNER ADDRESS V 1 / CCrTY/STA G <br /> CONTRACTOR T VL 1/-) ice` rn r /L ��pHONE V <br /> ,� C. D <br /> L <br /> CITY/STA P�"`' S� " J 7 <br /> CONTRACTOR AODRES r,/ N <br /> SUBCONTRACTOR Jnr PHONE C <br /> SUBCONTRACTOR ADDRES;i• I I L _ / J CRY/STATMP MA / <br /> LICENSE C•57 'V/ C-61 D-09 Other C/! NUMBER�O ExPrRAnON DATE v `� <br /> GEOGRAPHICAL INFOR ATION: Coordinates X Y Township_ Range Section_ <br /> i INTENDED USE VorneSticlPrivate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampfing/Characterization <br /> Public Water System <br /> If different from Owners Water SySteril NaMe Q0nt=N8Me ar KnOM NUMbW <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modfication Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical °of bwngs <br /> Out•Of-Service WWII ll <br /> Well Renewal Cross-Connection Repair <br /> New Pum ✓ Pum Re lacement Pum Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilfing Method Mud Rotary Air Rotary Auger Cable Tod Push Point Other <br /> Proposed Well Depth It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bagI15-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other is <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name)_ n <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width_it Len ft Thick in Christy Box Stove Pi e <br /> 114 3R=F= <br /> PUMP Submersible Turbine Other HP I 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 /> MINIMU9 24 HOUR ADVANCE NOTICE REQUIRED FO.RINSPECTIONS--PLEASE CALL(209)953-7697 W <br /> SIGNED / TITLE i/V L V Int^_YI DATE <br /> -aPAY <br /> a® - RED�IENr <br /> A% 04 <br /> 2016♦= SAN <br /> JOAQU <br /> K , hTAL <br /> -3 "EAL-, <br /> FPME <br /> �.. <br /> X -a-r 1 <br /> Uj a , I _ <br /> � � W g� <br /> l-- � � 1- <br /> " <br /> >., U L 2 5 2016 <br /> ac>s� <br /> � �vl h:4ER1TgL HEALTH <br /> MITiSEr? <br /> tqCES <br /> C:D ^ DEPARTMENT S `ONLY <br /> +....tar � `Application Accepted By`NDate $ � l� Area O `�- Employee ID#���' <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boning Inspection By Dat Constructed Well Depth ft <br /> COMMENTS f1.r) ! .! q \ <br /> PE Sc Received Chec Amount Data Perrrlkl Invoice WeOIDS <br /> Codes Info B Remitted ServiceR uset# <br /> 't6, <br /> oS� a 3�0 5 3 43 '`i-Id <br /> F.HO i'06 WELL/PUMP PERMIT <br /> .no,2 <br />