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16. vv* <br />wsmOL <br />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 INSP4CTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET V1 APN <br />SM <br />OWNER NAME PI?— <br />L //��SOWNER ADDRESS/ . • a' \ILL, <br />ADDRESS <br />CITYIZIP <br />– D <br />0 <br />'.CEL SIZE <br />(,,, . vL ND USE APPLICATION # m <br />U! <br />N <br />HONE <br />CITY/STATE/ZIP AkArQ%J YJ <br />PHONE <br />CITY/STATE/ZIP <br />1 <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE LV57 C-61 D-09 her C 16 NUMBER lq5A VOLE%PIRATION DATE-di.O 19 <br />i <br />GEOGRAPHICAL INFORMATION: COOrdinaf •JIS(P Y ownship _ Range Section_ <br />INTENDED USE Domestic/Private rrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />It different from Owner: Water System Name on a ame or Phone um er <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service Well o(Of-Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement 4ump Repair Raise Well Casing <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Dep ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth it Neat Cement (94 lb bag/5-f0 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant /-Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Ped! <br />VLd Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Setft Standing Water Level ft <br />I HER CER Y THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOA IN COUN ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CU RENT AND 'VE WITH THE ORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />W RKERS CO NLA <br />MINI U 24 H ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIG D – _ TITLE DATE 57-3/'U/7 <br />RFc NENt <br />' FD <br />Wo�DU� 130/21 <br />ROti, 4MFCO <br />RrWF� <br />EPrA TM ENT U E NLY <br />Application Accepted By I ate ,lQp. Area Employee ID#��..`�� <br />Grout Inspection By Dale SPECIAL Well Permit <br />Pump Inspection By Mf2aee Date -1 WAIVER Received <br />Soil Bofing Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />