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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVVIV-KLF UNUAULt I"EKMI I <br />LALL ILI V) lf*J-1691 FUR IN5PtGTIUN5 tAYIKCS l TEAR FRUM WAIL 155UEL <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />1^ <br />ltd 1524M <br />JOB ADDRESS -�7 <br />r�// <br />1y2NjCITY/ZIP �d <br />CROSS STREET <br />� <br />APN PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME <br />, 1`� PHONE <br />OWNER ADDRESS S/�/ <br />I^^'yAy'( <br />PG f Yr �l � �1 �I � CITY/STATE/ZIP <br />CONTRACTOR Va <br />/ L/f <br />1 <br />i I liV0 PHONE <br />CONTRACTOR ADDRESS r <br />{� <br />W <br />CITY/STATE/ZIP ��GI'� �•.J{(J�(� <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE X C-57 . C-61 D-09 t. Other NUMBER 'O�I _J� ExPtRAnON <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE DomestictPrivate -; Irrigation/Agricultural Industrial �i Water Quality Monitoring I[ Soil Sampling/Characterization <br />Public Water System <br />If different from Owner, Wate, Sytem N.me (.;orftd Nam or Phone Numbw <br />TYPE OF WORK )(New Well - Replacement Well Well Alteration/Modification C Other <br />Monitoring Well(s) # of wells - Soil Bonng(s) # or borings Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair ; Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method T Mud Rotary Air Rotary Auger i Cable Tool r Push Point Other <br />Proposed Well Depth ft Excavation —`-� in diameter Open Bottom Gravel Pack/Gravel Size I y _ in diameter <br />c Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Scher�S&n F44 Steel'Plastic ! Stainless Steel i= Other <br />Grout Seal Depth_ n ft 1 1 Neat Cement (94 Ib bag/5-10 gal water) Sand Cement_ sack mixR gal water <br />i Bentonite (20% solids) i i Other <br />Grout Placement Method Pumped i Free Fall i Other Retardant / Accelerator (name) <br />P TA Installed By 4 Driller i. Pump Contractor,, _. Other <br />i Concrete Pedestal' Dimensions: Width it Length 3 R Thick C in r IChristy Box I Stove Pipe <br />PUMP Submersible - Turbine Other HP_IV IPump 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 />MI�N ,M�24 HOUR, ADVANCE NOTICE REQUIRED FOR INSPECTIONS - ,PLEASE CALL (209) 953-7697 <br />SIGNED '��V"�"+w TITLE `/►Gr.2iSI(lt� DATE <br />U) <br />m <br />0 <br />m <br />N <br />¢DEPASP ON Y <br />Application Accepted By f� Date Area V 9 Employee ID#—" <br />Grout Inspection By Date ❑ SWell Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By //D�ate 1 Constructed Well Depth <br />COMMENTS S=i�I�a 2Lfi !✓P L5_`;-t7a1/ t/ie!A/e W-40 -411 dal c'oitUif <br />PE <br />Codes <br />ISC Received <br />Info B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date PermI <br />Service Request # <br />Invoice# Well 1D# <br />3�� <br />18h <br />3 <br />� <br />(Po W <br />003 0 <br />3 p v u 1& y jr� 1r�rEU/PUMP PERMIT 1 <br />