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M7 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT11 CALL 200J9 953-7697 FOR INSPECTIONS I EXPIRES 1 YEAR FROM DATE ISSUED <br /> ✓ <br /> ` JOB ADDRESS Mf 1 I` r+ CITY/Zip LOA-, C P, 9 sa g a o <br /> D <br /> ♦ CROSS STREET,_I`^r. 1 T U(n{- Z r7. APN PARCEL SIZE'3 —LAND USE APPLICATION# <br /> \ N <br /> OWNER NAME Tc o -f y M cx \n PHONE H <br /> OWNER ADDRESS CITY/STATE/ZJP 2(/] �J <br /> CONTRACTOR V x'111 1 VR \11 \^\� PHONE <br /> \ 361 _/��77-i <br /> CONTRACTOR ADDRESS •O ' IXJ `l CITY/STATE/ZJP Gq 1 T) CA q S Co 3 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CI <br /> T <br /> Y/STAT <br /> E/AP <br /> LICENSE C-57 /-4,C-61 _:D-09 Other NUMBER �\-1�7`�� EXPIRATION DATE 7-3)-18, <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE DomestidPrivate Irrigation/Agricultural 1 Industrial ❑Water Quality Monitoring i Soil Sampling/Characterization <br /> i Public Water System <br /> If different from Owner Water System Name o a .—or one um <br /> TYPE OF WORK �"eW Well a Replacement Well Well AReration/Modification I Other <br /> -I Monitoring Well(s) #of wells Soil Boring(s) #of borings i Geotechnical #of bonngs <br /> F,Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> ew Pum -i Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary I Air Rotary Auger Cable Tool - Push Point Other <br /> Proposed Well Depth qUn ft Excavation 1_in diameter -i Open Bottom )4 Gravel Pack/Gravel Size 114- in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter.L In Thickness/Gauge/ASTM Sched C aU i I Steel �K Plastic ❑Stainless Steel i I Other <br /> Grout Seal Depth ( ft I J Neat Cement(941b bag15-10 gal water) )4 Sand Cement 1().3 sack mix17 gal water <br /> L Bentonite(20%solids) ,-i Other <br /> Grout Placement Method XPumped Free Fall . Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By XDriller Pump Contractor Other <br /> Concrete Pedestal,Dimensions:Width 3 ft Length 3 It Thick_(�_in i Christy Box 1 Stove Pipe , <br /> PUMP Submersible-Turbine I Other HP_2CL__ Pump Set__1�2G 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 /> MIN M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> INSPECTIONS-PLEASE CALL(209)953-7697 1-7 <br /> SIGNED C TITLE J f�C 9rif 'e Y) DATE ` / ``11 <br /> 'V <br /> S <br /> m � <br /> v <br /> SPANV1R0N A <br /> �7-111111 11111111 <br /> DEPARTMENT USE NLY <br /> Application Accepted By Area Employee ID# � � <br /> Grout Inspectio y ate ❑ SPECIAL Well Permit <br /> Pump Inspection By Date -1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed We..Depth U7 ft <br /> COMMENTS L. Z P <br /> IWI <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info 8 as Remitted 1' Service Re uest# Pl1 <br /> i34 PK7 -17q7- '7W Z ^ <br /> e,• <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 1 4/30/12 `-�Vf'iCJ <br />