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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 - (209)466.3420 <br /> NON-REFUNDABLE PERMIT I CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> jJOs ADDRESSl/ r�{�__ i PARCEL SIZE D• ) ^C"/Zlp- `0 E 4 <br /> CROSS STREET IC Z Q '• APN f D � <br /> �r yELAND USE AP, /APPLICATION# m <br /> OWNER NAME �lll L PHONE �v 3 J D O go <br /> OWNER ADDRESS kw*I _ __.___ CITY/STATE/ZIP G� <br /> CONTRACTOR �"'4 �S ,'4 I�' PHONE - J q_ [ -7 2-S <br /> CONTRACTOR ADDRESS _ CITY/STATE/ZIP 4 Lj ? � <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS a�CITYISTA'TjE21P <br /> ,LICENSE 57 C-61 D-09 Other NUMBER J0� EXPIRATION DATE <br /> ---- --—--- -------- - <br /> GEoGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE >4tomestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Charactenzation <br /> Public Water System <br /> If different from Owner --- Water em ae Name wre Number ---- -- <br /> TYPE OF WORK><New Well Replacement Well Well AlterationlModification Other <br /> Monitoring Well(s)_—#of wells Soil Borings) z of borings Geotechnical____#of bonnpa <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> '<New Pump Pump Replacement __Pum-p Repair <br /> WELL CONSTRUCTION <br /> Drilling Method--<Pud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth M) ft Excavat on.III——__in diameter Open Bottom yC�Gravel Pack/Gravel Size in diameter <br /> Conductor asing ___ in diameter / Conductor sing Depth_ it <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainl Steel Other <br /> Grout Seal Depth'2 it Neat Cement(94 Ib bag/5-10 gal water) and Cement_ .3 - sack mix/7 gal water. <br /> Bentonite(20%solids) Other <br /> Grout Placement Methodsy<pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contracto Other <br /> Concrete Pedestal Dimensions:Width Length it Thick in Christy Box Stove Pips <br /> �,PUYP 64Submersible Turbine Other HP Pump Set ft Standing Water Level it <br /> 1 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 /> MI /IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> gI <br /> SIGNED /� �//tN� TITLE lJ LJ 1,*12- DATE <br /> M1 0 17- <br /> M JC A <br /> 7-4 # �,—#-S'E T OIEP H _ <br /> _ DEPARTMENT USE ONLY <br /> Application Accepted A Date L `t Area 174_ _ Employee ID# c/t <br /> Grout Inspection y Date 5!56Z; SPECIAL Well Permit <br /> Pump Inspection - �Date WAIVER Received <br /> Soil Boring Inspection B _ Date Constructed Well Depth ft <br /> COMMENTS nL ' c E I N - 40L �( \ <br /> PE SC Received hoc Amount Date Permit/ Invoice# Well IDN <br /> Codes Info By ash Remitted Service Request# _ <br />