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"9 WELL/PUMP PERMIT P <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 OR INSPECTIONS EXPIRES 1 YEAR FR DATE ISSUED <br />JOB ADDRESS �✓ �+ l CITY/ZIP " p <br />1 <br />CROSS STREETV I "\,,' AP P ILI 2 PARCEL SIZE LAND USE APPLICATION # <br />An 0 <br />OWNER NAME , I/, I c P ONE //]� <br />OWNER ADDRESS110V I • ,r/'1 CITY% A P � 0 Q <br />CONTRACTOR �//y A /v P14 , ywok P�H�Oj1/{��) <br />CONTRACTOR ADDRESS �+ • % / CITYISTA J ✓V a <br />SUBCONTRACTOR 1 PHONE ffr <br />SUBCONTRACTOR ADDRESS fy 1A _ 77 CITY/STATE/ZIP !/ , Y <br />LICENSE C-57 V61 D-09 Other G// NUMBER�V EXPIRATION DATE ` / <br />s <br />GEOGRAPHICAL INF TION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE V Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: water 5ysteM Name GontaCt Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boringtt of borings s) Geotechnical S of borings <br />Out-Of-Servi a ell Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pum Pum Re lacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <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 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 bag15-10 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 />oncrete Pedestal Dimensions: Width ft Lengt ft Thic in Christy Box Stove Pipe <br />PUMP V Submersible Turbine - Other HP Pump Se[ ft Standing Water Level ft <br />�jj <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT fHt WUKK WILL III= UUNIt IN AwvWMUMN— wvlI , �. . <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE W THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKS MPENSA WS�ADVA <br />-MUM 24 O RTIC EQUIRED F INSPECTIONS - PLEASE CALL (209) 9 76/1 r r i► ri (P m G P1 DATE )9 / / Z <br />U1 <br />D <br />0 <br />A <br />N <br />W <br />Ilk <br />D E P A R T M E SE ONLY �/�y� /f <br />e�- 5 -1 � Area Employee ID# ' ` m� <br />Application Accepted By Date <br />Grout Inspection By Date =�—LCL / _ SPECIAL Well Permit <br />Pump Inspection By Date *J�]�VV t� WAIVER Received <br />Soil Boring Inspection By Data Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC Received ec <br />Info B ash <br />Amount <br />Remitted <br />Date <br />Permit/ Invoice # Well ID# <br />Service Request <br />j30 <br />090 a6 <br />-77- <br />� <br />wpor)37°ll <br />2 9 t� <br />""LTH <br />