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. - . jp�o scan <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 r/�l CALL (209 <br />09 953-7697 FOR INSPECTION , EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS K I / a A' v'1 d.p .� CITY/ZIP �� <br />CROSS STREET JU N Z IV OT PARCEL SIZE V - , _ 'LAND USg APPLICATION # �s <br />OWNER NAME •/ • • �� (/�/����t r /!,PHONE � <br />OWNER AODRES`S / 1 II SOL Ii V WVWCITYISTATEIZ V -fe <br />CONTRACTOR +rl) O ` v <br />1 n PHONE �) •� <br />CONTRACTOR AODRE_SS Y �� <br />N1 \\\w777111/,II' <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS_ 1 �Ir' <br />I ?0(0/ 0 <br />/CRY/STATE/ZIP <br />LICENSE C-57 )(Yk-61 D-09 OtherV NUMBER (0 Y' 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 dilatant from Owner: water System Name contact ame or one um er <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />C4 <br />MonitoringWell(s)_ #of wells SoilBoring(s) lofborings Geotechnical #of borings <br />Out-Of-Servic 4 Oat-Of-Sevice Well Renewal Cross -Connection Repair <br />law Pum p Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />/1 <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Sl\\ <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant I Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width it Length ft Thick in Christy Box Stqve Pipe <br />o 7Tl—�7S • �T.7— <br />PUMP Submersible Turbine Other HP. Pump Set ft Standing Water Level ft <br />1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN w <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, 1 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. C <br />MINI M 2�!2,4u" NOTICE REQUIRED FOR PL�E/A�SE CALL (209) -7697ALGNED TITLEYVJ_ L h J /_j& r ( DATE <br />RECE <br />MAR 2 <br />N' DEPARTM �3LtV00 <br />SE ONLY <br />IRPECENED Application Accepted By _ Date _ Area � � Employee ID# TIZ7' 0 -" — <br />Grout Inspection By _ Date SPECIAL Well Permit <br />APR 0 20� Pump Inspection By _ t Date WAIVER Received <br />Soil Boring Inspeption y Date_ Constructed Well Depth ft <br />sogQFNVkQIN COO LENTS lr r 6 <br />HE ,L.TT1 D6*ATMEMT-- __-- — <br />PE SC Received Che Amount Permit! <br />Date Invoice # Well ID# <br />Codes Info B Cash Remiun Service Re) # <br />o X333 53;"" 31- 6 iiZW ZH N? " 002 <br />EHD 43 OE WELL /PUMP PERMIT <br />L33 +2 <br />0 <br />