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WELVPU <br /> MP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)p953-7697 FOR INSPECTIONS /�EXPIRES 1 YEARFROMDATE ISSUED N <br /> JOB ADDRESS l CITY/ZIP! SlLLti �'(/ o <br /> Q -llo -l� 41-41—._ m <br /> CROSS STREET �cC�I `� APN PARCEL SIZ LAND USE APPLICATION# z <br /> n l U) <br /> m <br /> OWNER NAME � <br /> a � 1's �� ��Y� F'ONE y <br /> OWNER ADDRESS I �47C O� J CITY/STATE21P�����6� <br /> CONTRACTOR PHONE � <br /> CONTRACTOR ADDRESS `� e CITY/STATE/ZIP /y��►'L O 4e I L� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP I <br /> LICENSE >(,C-57 r) C-61 11 D-09 P Other NUMBER EXPIRATION DATE q-30 �CI <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural U Industrial [] Water Quality Monitoring U Soil Sampling/Characterization <br /> I I Public Water System <br /> If different from Owner: Water System Name ontact ame or one umber <br /> TYPE OF WORK )(New Well Il Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical a of borings <br /> ❑ Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> I I New Pump r] Pump Replacement ❑ Pump Repair 11 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary CJ Air I ry ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth—�an& ,1tf Excavation / in diameter ❑ Open Bottom Gravel Pack/Gravel Size_ in diameter <br /> Ll Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in ickness/Gauge/ASTM Sched 1CIn '3 SteelPlastic ❑ Stainless Steel— El <br /> Grout Seal Depth 17 Neat Cement(94 Ib bag/5 10 gal water) ❑ 5and Cement sack mix/7 gal water <br /> Bentonite 0%solids) !j Other <br /> Grout Placement Method t Pumped ❑ Free Fall Other I1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 'Pump Contractor ❑ Other <br /> Concrete Pedestal;:Dimensions:Width ft Length ft Thick in ❑ Christy Box P Stove Pipe <br /> PUMP f- Submersible[! Turbine 11 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 COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED_•- ✓ ► `� TITLE v'f II2:- DATE <br /> i <br /> I 4 )Prj -LLV Lip <br /> - y <br /> I- <br /> E qVI RO qM N AL <br /> T E T <br /> ETMENT U E NLY ?� <br /> Application Accepted By Date Area k Employee ID#4 "[./ <br /> ,w Grout Inspection By 1Aate ❑ SPECIAL Well Permit <br /> O`er Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Ins ection By Date truct d W II Depth ft <br /> \ OMMENTS <br /> V <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> nn <br /> 3`( '� 0 6 WPao 3 <br /> EHD 43.06 WELL/PUMt'PERMIT <br /> 4/30/12 <br />