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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-31"�.,t� <br /> NON-REFUNDABLE PERMIT n ,' CALL/209 963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE9,0,?*•- <br /> q�p eR411f4 124a Cm2iP // r 4' <br /> JOB ADDRESS �/ ! �y q 3 (. <br /> CROSS STREET M 4 i4rN I*I AVC AP/N J R a d-Z Dl(B PARCEL SIZE 3�LAND USE A�PP^U/CATIOlNf#p( <br /> OWNER NAME S-1p.4/��-. eAQ)h O—�,(�i///1 PHONE /��-V`I��A-/ <br /> OWNER ADDRESS D& 'e- to/�h #-$a CITYISTATEMP F renes• <br /> CONTRACTOR �t.l 40. /yI-rueoyyao^ _0//fx ,�� 1-dell, <br /> ,/ 1(���0I <br /> CONTRACTOR ADDRESS god 1.rnfket./a( VVwy CITYISTATEOP L--dK� C/7 9�^/O <br /> SUBCONTRACTOR !V//T PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEMP 2 <br /> LICENSE )OC-57 G-61 D-09 Other NUMBERe?� ExPIRAnoN DATE ✓ <br /> GEOGRAPHICAL IWORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE DOrnestic/Prlvale Irrigalion/Agricuitufal Industrial Water Quality Monitoring NSoii Sampling/Charactertzation <br /> Public Water System <br /> it Aserenl hom Owner er System Name U.Naid N.—or ne Num , <br /> TYPE OF WORK New Well Replacement Well Weil Alteration/Modification Other <br /> Monitoring Well(s) s of wells Soil Boring(s) a o1 twrings XGeotechnicals or borings <br /> Out-O(-Service Well Out-Of-Service Well Renewal Cross-Conneelion Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method %Mud Rotary Air Rotary )CAuger Cable Tool Push Point Other <br /> Proposed Well Depth-3D fl Excavation in diameter Open Bottom Gravel PacklGravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(941b bag's-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) IIII ^ % :ft G*14060-tt- <br /> Grout Placement Method Pumped Free Fall Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length ft Thick-_ _in Christy Box Stove Pipe <br /> lame Submersible Turbine Other HP Pump Set___ _ft Standing Water Level fl <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 CO NSATION LAWS. <br /> MIN OUR NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)963-7697 <br /> SIGNED69� TITLE�i />irft &tl DATE <br /> DEPARTMENT SE PNLY <br /> Application Accepted By _ Date L l ( - Area O l Employee ID# u y-"V ✓ <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By WAIVER Received <br /> Sod Boring inspection B e Constructed Well Depth ft PAYMENT <br /> COMM TS RECEIVED <br /> PE Sc Receivedas Amoug Date Permw Invoice# Well ION F r ti 17 2015 <br /> Codes Into B Cash Remitted Service Request n <br /> SAN JOAQUIN COUNTY <br /> EwROMMAL <br /> HEALTH DEPAH711E31T <br /> EHO 4346 <br /> WELL(PUMP PERMIT <br /> IrlUn1 <br />