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N4isso90 <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 (ZU9) 953-7697 FOR INSPECTIONS tAVIKll /'I TER FROM DATE ISSUED <br />JOB ADDRESS �I 1����A Rd /7 CITY/ZIP I�z thso" / 2 � � <br />CROSS STREET 04 Ila r fm o T APN C� (J — — V0) PARCEL SIZE 0-3 / f "LAND USE APPLICATION # <br />OWNER NAME�I ♦ a��� PHONE <br />OWNER ADDRESS '2,bZ17 CITY/STATE/ZIP <br />CONTRACTOR /V PI I O- 4,7 d e'lka 1F(1 I PHONE <br />CONTRACTOR ADDRESS qU h (i U/1S fµAGl) %� CITY/STATE/ZIP I�CA ,�cnT 7 Z 7Q <br />SUBCONTRACTOR / �/ /// PHONE <br />SUBCONTRACTOR ADDRESS �/ CITY/STATE/ZIP <br />LICENSE )(`6-57 C-61 D-09 Other NUMBER GU EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring )(Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(S) <br /># of borings K Geotechnical �3 # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair p'�� <br />New Pum Pum Replacement Pum Repair <br />Raise Well Casin 1� <br />WELL CONSTRUCTION <br />ecel <br />Drilling Method ,"ud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth to _ k ft Excavation in diameter <br />Open Bottom Gravel Pack/GravelN 2�,,irjpdiameter <br />U 20 <br />Conductor Casing in diameter / Conductor Casing Depth ft SAN J <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched <br />n',' <br />Steel Plastic Stainless SteetN �� <br />Grout Seal Depth ft "eat Cement (94 Ib bag/5-10 gal water) <br />Sand CementNEAUNK� I water <br />Bentonite (20% solids) Other <br />NARrMEIUT <br />Grout Placement Method Pumped Free Fall Other <br />Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length <br />ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP <br />Pump 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 />EP TM U E ONLY <br />Application Accepted By r Date /V <br />Grout Inspection By If Date <br />Pump Inspection By Date <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />l <br />Area Employee ID#Am" <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />Iii <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />B <br />,-Cheek# Amount <br />s Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />22,7 <br />31 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />