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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)488-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 115.�✓o �i•• 1"�I(a��t �_F� CITYIZIP��� 1 ✓�� y <br /> CROSS STREET �yt� 1 ll JAPN O C "1 O0EL SIZE / LAND USE APPLICATION M <br /> In <br /> u <br /> OWNER NAME <br /> S PHONE w <br /> OWNER ADDRESS , / )' CITYfSTATEtZP <br /> CONTRACTOR �/[J��11 lI��V ✓(yl l I(� PHONE <br /> CONTRACTOR ADDRESS {jI/� CITYISTATEIZIP_ III, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS _ CITYISTA�TpFJLP �7 ?I <br /> LICENSE X C-57 C-61 D-09 Other NUMBER ? � 3 EAPIRAnON DATE7—_' L, <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE )(Domestic/Private Irigation/Agrialttural Industrial - Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If diftrent nom Owner a r '"nn .— c,ontiid N—or Phone um r <br /> TYPE OF WORK r New Well Replacement Well - Well AlterationiModification Other <br /> Monitoring Wefl(s) 9 of wells Soil Boring(s) a of oonngs Geotechnical a of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> _ )C New Pump Pump Replacement C Pump Repair _Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Y,Mud Rotary AT Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth Se-tt fl Excavation I in diameter Open Bottom Y Gravel Pack/Gravel Size_y{�In diameter <br /> Conductor Casing in diameter f Conductor Casing Depth ft <br /> Well Casing Diameter In ThirdmessfGauge/ASTM Schede.Steel )(Plastic Stainless Steel Other <br /> Grout Seal Depth _ft Neat Cement(94 Ib bag/5-10 gal water) x Sand Cement JOS sack mlzf7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method k Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Wriller Pump Contractor Other <br /> oncrete Pedestal Dimensions:Width_5__R Length _7 R Thick�_in Christy Box Stove Pipe <br /> Pure S ibmersible Turbine Other HP Pump Set R Standing Water Level _ If <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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED '' Q Z TITLE DATE qN1 iS <br /> I — — <br /> ZW o L) t - c - <br /> d. <br /> W > ; u - <br /> � W _M <br /> - - <br /> �U C'- 4 - <br /> a� u - <br /> z o _ <br /> in 79a- I <br /> DEPARTMENT USE ONLY <br /> Application Accepte,J4,;�. <br /> Date Area o4 Employee IDaIIGrout Inspectlor Date 6 0 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By_ Date Constructed Well Depth R <br /> COMMENTS�4_1 �Ir.1 f—�—�.� L 'k- 1-* �I'l <br /> PE SC RaeNved Chec:110 Amount Pe iv Invoice a Well IDs <br /> Codes Info B Cash RemKbed Data Service Request# <br /> 7?g q( S�Z0o'73 9s -- <br /> �nJi 7 3r4 <br /> EMD 43-Oe WELL r UMP PERMIT <br /> b 112 <br />