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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 14M <br /> 7 l/&6m! i¢ /�'V^ m <br /> JOB ADDRESS CITYRIP G <br /> CROSS STREET —APNSIZE LAND USE APPLICATION <br /> m <br /> OWNER NAME / �[�J_I � , /� / ' ���r/'/� � PHONE -✓ ���� N <br /> 4f mz�+s S3 <br /> OWNER ADDRESS / JU L ��� G�— CITY/STATE/ZIP / <br /> CONTRACTOR LSI /� PHONE <br /> CONTRACTOR ADDRF,SS �` ZG ' CITY/STATE/ZIP S ✓� <br /> SUBCONTRACTOR Y��L-L�iC� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE Y�-57 -61 i I D-09 11 Other NUMBER�s�'�G EXPIRATION DATE 11j-1 17 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 1j Domestic/Private F Irrigation/Agricultural U Industrial O Water Quality Monitoring 0 Soil Sampling/Characterization <br /> H Public Water System <br /> If different from Owner: Water System Name ontact ame or hone umber <br /> TYPE OF WORK n New Well replacement Well G Well Alteration/Modification 0 Other + <br /> 0 Monitoring Well(s) It of wells C Soil Boring(s) #of borings I- Geotechnical It of borings <br /> 0 Out-Of-Service Well U Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> New Pum D Pump Replacement 0 Pump Repair 11 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑ Air Rotary n Auger U Cable Tool Cl Push Point ❑ Other <br /> Proposed Well Depth 7­15T ft Excavation in diameter 11 Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑ Conductor asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched U Stee�lastic C Stainless Steel 0 Other_ _ <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ,,Identonite(20%solids) 1 Other <br /> Grout Placement Method L 1 Pumped D Free Fall r, Other [7 Retardant/Accelerator(name) <br /> PEDESTAL Installed By U Driller 10ump Contractor 0 Other <br /> r! Concrete Pedestal F Dimensions:Width ft Length ft Thickin Fl Christy Box 0 Stove Pipe <br /> PUMP I ubmersible U Turbine I; Other HP�_ Pump Set ft Standing Water Level -4t <br /> I HEREBY CE TIFY 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 COMPENSA <br /> TION LAWS. <br /> MI� ADVAN,�CCE�,NOTICE REQUIRED FOR I 'SPPECCTIONS- PLEASE CALL (209)95 76 7 <br /> SIGNED jL /��fY TITLE DATE a <br /> LO <br /> �r <br /> 6 <br /> • L� <br /> JVA <br /> N C U <br /> LT p P <br /> boll <br /> L <br /> I <br /> FT 11 i <br /> JQ, <br /> EP TMENT YSE PNLY qq <br /> r <br /> Application Accepted By Date vv Area Employee ID#-� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By (lZ bGi*h Date ❑ WAIVER Received <br /> Soil Boring IWpection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> Ole ko I 5aD LOFaD S�rQl <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4130/12 <br />