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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-L697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> CITV/ZIP <br /> JOB ADDRESS < < R 1` ! D <br /> O <br /> CROSS STREET 1 APN U ..-- PARCEL SIZE��LAND USE APPLICATION# m <br /> 'A N <br /> OWNER NAME r� /� l /I ,PHONE N <br /> OWNER ADDRESS L l.'1 0 CITY/STATE/ZIP `—r i r-, Q [/Z2�13 <br /> CONTRACTOR Vel _ cP/HONE ` 71)—. <br /> CONTRACTOR ADDRESS ' I. CITYISTATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> ._ SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE G57 ❑C-61 D-09 .1 Other NUMBERat, �L• ExPIRATION DATE 17 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE "� Domestir/Private -Inigatlon/Agricultural -i Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> 7 Public Water System <br /> If different from Owner er ystem Name Contact Name or Phore Number <br /> TYPEOFWORK 7 New Well Replacement Well 7 Well AReration/Modifioation Cl Other <br /> Monitoring Well(s) #of wells :=Soil Boring(s) #of mnngs Geotechnical #of borings <br /> Out-Of-Service Well ,Out-Of-Service Well Renewal J Cross-Connection Repair <br /> _New Pump C Pump Replacement YPump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 7 Mud Rotary G Air Rotary I Auger Cable Tool -. Push Point G Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom D Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel - Plastic 'I Stainless Steel Other <br /> Grout Seal Depth ft G Neat Cement(94 Ib bag/5-10 gal wafer) Sand Cement sack mix/7 gal water <br /> I Bentonite(20%solids) -i Other ' <br /> Grout Placement Method D Pumped ❑ Free Fall Other =Retardant/Accelerator(name) / <br /> PEDESTAL Installed By Driller C Pump Contractor i7 Other 1 <br /> O Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe V, <br /> PUMP ❑Submersibie Turbine -1 Other HP Pump Set L it 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 1 ` <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M 24 HOUR ADVANCE NOTICE REQ I'{ 101 FOR INSPECTIONS <br /> SIG Ih M TITLE `�r✓- DATE <br /> IR N <br /> NT <br /> . O PARTMENT US O LYid ��� <br /> „�► SLI <br /> Application Accepted By ate 1 Area Employee ID# <br /> Grout Inspection By � o Date ❑ SPECIAL ell Permit <br /> Pump Inspection B / Date //Z� �/ L-1waVER Received <br /> Soil Boring In ection By Date Constructed Well Depth ft <br /> COMMENTS %����"G L��Z; Cv ��1P1't 2�v ✓b �J f"�/lG�y/Z�f t c:'Z !�'/ - o:7 4/ aa;- , —f-- v' <br /> /�o%L3�L.'l � 'rJf�'L�'S i�l� - �5 t%t-Li v ' fZD� L ,�cfs-Y� C� _ -C�I.E��✓ <br /> PE I SCReceived Chec Amount Date Permit/ Invoice# Well ID# <br /> Codecs 1 Info B Cash Remitted Service Request# <br /> 3” tDl6 / 2oc� �z <br /> EH D 4706 WELL/PUMP PERMIT <br /> 8!04/06 <br />