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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABLE PERMIT , , V CALL (22009 95.3.-776'97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS f�+wee����1��V OS4 Z j"`r%�wa�l. y Cm21P k b -' �J J <br />li <br />CROSS STREET v�.'�(eOA( APN O L J b LQ I PARCEL SIZE <' LAND USE APPLICATION(#� <br />OWNER NAME !( <br />fes' � PHON���0 <br />OWNER ADDRESS LZ Z- ,r u1 44, -e— CITY/STATE/ZIP <br />CONTRACTOR PHONE <br />ftm CONTRACTOR ADDRESS /..f�..�7 ebKN!%��f YL CITY/STATE/ZIP c CA <br />e/� <br />n :) It <br />SUBCONTRACTOR \�7� - I_ -t PHONE 44J n.3 - vfu'4` <br />SUBCONTRACTOR ADDRESS , � CITY/STATE/ZIP �VZ (26. Q2'A`7-)�, <br />LICENSE C-57 C-61 i. D-09 f4 Other NUMBER L�ss/(0V_ EXPIRATION DATE V� _�V <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br />INTENDED USE Domestic/Private M inigation/Agricultural `I Industrial r7 Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: water System Name GontaCt Name or Prone Number <br />TYPE OF WORK Ir New Well Replacement Well F Well Alteration/Modification Other <br />Monitoring Well(s) # of wells C Soil Boring(s) #0 <br />°rime U Geotechnical # of bo—gs <br />Out -Of -Service Well F Out-OfService Well Re wal Cross -Conn 'on Repair <br />New Pum Pum Replacement i' Pum Repair Rai: ell as <br />WELL CONSTRUCTION <br />Drilling Method { Mud Rotary Air Rptary F Auger I Cable Tool F Pu P t r <br />Proposed Well Depth 9 Excavation / 0 in diameter O ttom ^ Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casin Depth ft <br />Well Casing Diameter X in Thickness/Gauge/ASTM Schad Steel XPlastic ❑ Stainless Steel ii Other <br />Grout Seal Depth.j.� ft X Neat Cement (941b baa/5-1F F Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method It Pumped Free Fall I ; Other :; iardant / Accelerator (name) <br />PEDESTAL Installed By -- Driller Pump Contracto Other <br />-- Concrete Pedestal Dimensions: Width Length ft Thick in it Christy Box Stove Pipe <br />PUMP _ Submersible Turbine Oche HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED PLICA N AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDIN N ES, STATE LAWS, N ULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WI THE CALIFORNIA T ORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATI LAWS. <br />MI OUR AD E NOTICE REQUIRED F INSPECTIONS <br />� PLEASE CALL (209) 9-Y-7697. <br />SIGNED TITLE 1Q \Z3L�a DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Iggpection By <br />DEPARTMENT US10 <br />E,6LY <br />- <br />/ Date <br />Date <br />Date <br />Area Employee ID#�!} <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well-Qepth ft <br />RE Y�FN <br />APR cF��FD <br />2241 <br />V /%O CO <br />�6 <br />OFp O 4tWry <br />t4iFM' <br />r 'P///-7 <br />PE SC Received <br />Codes Info B Cash <br />Amount <br />Remitted <br />Date Permit'Invoice # Well ID# <br />Service Re uest # <br />41 <br />vc <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30112 <br />