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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE - STOCKTON CA 95205 • (209) 468-7420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JoBADDRESS ( &V tN Z� l- I�[ �W �' / �� CITYPN16-� <br />(�Si ► <br />tJ. <br />CROSS STREET W APN OS -3 P RCEL SIZE _LAND USE AP.P/T <br />LICA/ON-7# <br />OWNER NAMEcPHAONf�I <br />-E " [-7Gat) IOL <br />OWNER ADDRESS v '�-r~-�r S S l� CITYISTATElLP <br />CONTRACTOR ��-^-'r""�'�(�-✓y <br />' S PHONE 4�J( p(C1'70 <br />CONTRACTOR ADDRESS �Z' CITY/STATEJZP !%�li"\ <br />CA <br />SUBCONTRACTOR int V✓ � �� PHONE �Zl `6`� 77 CSD <br />SUBCONTRACTOR ADDRESS _ 1133 CITYISTATEILP_ C�j / ( T-✓ l <br />,x7-57 C-61 D-09 Other NUMBER ExPIRATION <br />GEOGRAPHICAL INFORMATION: Coordinates V"a­p Y Township Range Section <br />INTENDED USE DomesticlPrvate ImgalicNAgricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If diflment from Owner wave, 5YSIIMNa" --oC ntacTF)ame or ne Nurnbe, <br />TYPE OF WORK New Well Replacement Well Well AlleraliondMiedifieation�wfher _ <br />Monitoring Well(s) # of wells Soil Boring(s) e w nes Geotechniral 'Y of b0°rte <br />Out -0f -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />wELL CONsiAucnoN <br />Drilling Method Mud Rotary Air Rotaryuger GI <br />Cable Tool Push Point Other <br />Proposed Well Depth�; C> fl Exw anon in diameter Open Bottom Gravel PacklGravel S:ze3 �nldtameler <br />Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter_?_ !D- ThicknesslGauge/ASTM Sched !11.) Sleelaslic Stainless Steel Other <br />Grout Seal Depth /- < ft ,Real Cement (94 Ib bag/5-10 gel water) Sand Cement sack mall gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped >4ree Fall Other Retardant I Accelerator (name) <br />PEOESTAL Installed ByWriter Pump Contractor Other <br />COncreta�tal Dimensions Width ft Length It Thick in Christy Box tAlove Pipe <br />PUMP Submers;ble Turbine Other HP 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 COMPENSATIONI_AWS. <br />MINIMUM =3e NCE NOTICE REQUIRED FOR IN ECTIONS - P EASE CALL (209) 953.7697�f <br />SIGNED /, TITLE r t DATE 3u `OL <br />PA TMENT USE ONLY <br />Application Accepted By Date <br />Grout Inspection By Dale <br />Pump Inspection By Date _ <br />Soil Boning Inspection By AIFtG lAn,i Date Z ZQ <br />COMMENTS <br />IN <br />c1 <br />-,/VL" 1' � <br />�'f <br />44 7)y0 V FM� ��TY <br />Are Employee ID#� <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC Received ChecldA Amount Date Permit/ Invoice # Well ID# <br />Into B Cash Remitted Service Re uest # <br />8 Pct- .i <br />EHD12 / /���� WELL /)UMP PERMIT <br />