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' WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT1868/ 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT ' Bi-�5 -7697 FOR INSPECTIONS EXPIRES 9 YEAR FROM DATE ISSUED <br /> J1 t (n <br /> JOB ADDRESS CITY/Zip <br /> S <br /> ,r n ' D <br /> CROSS STREET �/ , API''" SI -�� � , C <br /> PARCEL SIZJE /1AND USE APPLICATION# p <br /> OWNER NAME PHONE <br /> I <br /> OWNER ADDRESS /4 0CITY/STATEIZIP <br /> CONTRACTOR / PHONE C' ?1"-C1-2 .L7 <br /> CONTRACTOR ADDRESS , CITY/STATT97JP C <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> ' LICENSE -57 61 i D-09 i Other NUMBE i- EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private i Irrigation/Agricultural •Industrial I Water Ouality Monitoring ! Soil Sampling/Characterization <br /> ' -- !Public Water System n --- <br /> 11 dillic tram Ovsle nr ys am Contact NaM or Phano NUm r <br /> TYPE OF WORKNew Well Replacement Well Well Alteration/Modification n Other <br /> Monitoring Weil(s) #of wells Soil Boring(s) a or borings Geotechnical oI boring <br /> Out-Of-Service Well Oul-Of-Service Well Renewal Cross-Connection Repair <br /> ' 00ew Pump � Pump Replacement �- Pump Repair : Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ($Aud Ro Air Rotary Auger Gable Tool i Push Point I Other <br /> Proposed Well Depth It Excavation�in diameter ij Open Bottom XGravel Pack/Gravel Size a in diameter <br /> ' ' Conducto Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad 1,Steel KPlastic Stainless Steel Other <br /> Grout Seal Depth_j rte[^> ft Neat Cement(94 lb bag/5-10 gal water) X Sand Cementza. sack mixl7 gal water N <br /> Bentonite(20%solids) ,Other _�I <br /> Grout Placement Method umped Free Fall !Other Retardant/Accelerator(name) h <br /> PEDESTAL Installed By Driller L Pump Contractor, Other N <br /> —XcConcrote Plidestal Dimensions Width _ft Length It Thick in I Christy Box Stove Pipe <br /> n <br /> PUMP Submersibles.!Turbine !011ier HP= Pump Set U R Standing Water Level ft <br /> ' I HEREBY CEfRTIFY 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 /> AINIP 24 HOUR ADVANCE NOTICE REQUIR D FOR INSPECTIONS <br /> 14 <br /> SIGNED J TITLE DATE -7/Z <br /> \. <br /> 15 <br /> _ `lMEMJT <br /> CENED <br /> LZP4— JY 2012 <br /> S G - , { <br /> �_ i_ ;U!N COUNTY <br /> MENTAL <br /> 'DEPARTMENT USE ONLY <br /> ' Application Accepted By Oate Area Employee 1D# <br /> Grout Inspection bate SPECIAL Well Permit <br /> Pump Inspection Ifr Date WAIVER Received <br /> ' Soil Boring Inspection By Date Constructed Well D ith ft <br /> k C. <br /> MENTS (. L.. 7K N C i J .1 1�-FL W7 l i>C 9 CC U <br /> COm <br /> i <br /> ' PE SC Received Check#/ Amount Permitl <br /> Date Invoice# Well ID# <br /> Codes Info B Cash RemNted Service oast# <br /> Lay' l Cr ter. I�s�l�. 5R'Oo (pLf'�5 <br /> LE3M 6)s"7) 53 I'LG�-(0L( <br /> ' C-Hp 47AG �-�(-, 7'7t I /♦♦�� WELL/PUMP PERMIT <br /> al04/0a -f-"" <br />