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WELL/PUMP PERMIT ,,!eII7, ° <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 INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �s-�I �I`� ' S� CITY/ZIP qYagD <br /> CROSS STREET/IY]•K /.�, RkD-'iC A1Iol&f/4(APN C3_5 PARCEL SIZE LAND USE APPLICATION# m <br /> OWNER NAME Joon- Ll/o� , PHONE S/-n ,, ql`7. 7l(?_3 <br /> OWNER ADDRESS _ `/ �1 CC?�/a�/f `9V��7� 7 CITY/STATE21P A�QlLtJ7 <br /> CONTRACTOR /�A Cl.-TI, -7 PHONE /4 5-- 5"2 C <br /> CONTRACTOR ADDRESS S r/ CITY/STATE21P;LA e/.J <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE "-57 1 C-61 1 D-09 11 Other NUMBER Y EXPIRATION DATE 5-3/' <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> [LNTENDEDUSE omestic/Private Irrigation/Agricultural CJ Industrial Li Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 11 Public Water System <br /> If different from Owner: Water System Name intactameN or Phone Number <br /> er <br /> TYPE OF WORK ergew Well Il 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 Ll Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> R New Pump 11 Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 4T-ffu_d Rotary Ci Air Rotary Ci Auger Ll Cable Tool L1 Push Point 0 Other <br /> Proposed Well Depth 3d� <br /> p p ft Excavation - IA6_ in diameter I Open Bottom O'dravei Pack/Gravel Size in diameter <br /> U Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter$'in Thickness/Gauge/ASTM Sched f� 'i Steel RYPlastic C Stainless Steel ❑ Other <br /> Grout Seal Depth I( + It ' Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> U-S—entonite(20%solids) I 1 Other <br /> Grout Placement Method dumped '=1 Free Fall F Other U Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 7 Pump Contractor 1 Other <br /> Concrete Pedestal 'Dimensions:Width ft Length ft Thick in i 1 Christy Box ❑ Stove Pipe <br /> PUMP Submersible Turbine I; Other HP Pump Set It 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 A D ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C MPENSATION LAWS. <br /> MI IMU OUR ADVANCE NOTICE REQUIRED FOR INSPECTIO/N P •ASE CALL(209)953-7697 <br /> SIGNED TITLE P� ,/S� DATE <br /> J` N <br /> V� / C <br /> r <br /> if <br /> Avn <br /> 0 <br /> 0 <br /> N <br /> w (1 <br /> r• <br /> i <br /> I '_. �L. Q pS I �i i I I j <br /> D PARTMENT UfiZ ONLY <br /> Application Accepted ate 10 1201 Area 'l Employee ID# IJ <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By 1 Date Constructed Well Depth __ft <br /> ✓ COMMENTS <br /> (01 1/ /4'0/ 5 u y <br /> PE Sc Received �hec Amount Permit/ 1 <br /> w Codes Info ash Remitted Date Service Request# Invoice# Well ID <br /> (0,7313 �.°� 10 1 (V/ 5e.t67Vt)0 <br /> EHD 43-06 WELL/FUMP PERMIT <br /> 4130/12 <br />