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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTYM11Ro�FHT11L HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT ++11CALL 209 953-7697 FOR <br /> INSPECTIONS I 'EX'1PIRES I YEAR FROMDATEISSUED <br /> JOB ADDRESS [ � I��c u S l `I-'C�(-' '1T\ 1 CITr17jp yKA t i 1 5 L�`J m <br /> CROSS STREET I4 VJ T I cal V 1 LAV APN C )\t 2-V PARCEL SQL U(0 LAND UsE APPLICATrON 8 <br /> I 1 mw <br /> OWNER NAME 4'X4`` /4 ILj`%1V4Ij- \ 1 f _ PHONE 4 <br /> OWNER ADDRESS CrTYlSTATE/Z)P L``�'�ONe I ysa 40 <br /> CONTRACTOR V 1 li 7 P�HOW 3(,,q - R-779 <br /> CONTRACTOR ADDRESS C_- 1)tl 1' CITY/STATE/LP (/.�v q 1 A-ii C A 5 5C-3 a <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/LP <br /> LICENSE -57 ),4 -61 D-09 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE Domestic/Prtvale 7llmgaborVAgnculturel Industrial Water Quality Monitoring Sad Semping/Charactenzation <br /> PubliC Water System <br /> 11 dllsr.M Rom Owrrr W.W, y,em .— emr of ne u <br /> TYPE OF WORK New Weil Replacement Well Well Alleration/Modrfication _ Other <br /> Monitoring Well(s) S of wells Soil Bonng(s) a ul mnng. Geotechnical a of Mons» <br /> Out-( Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> ew Pum Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method xMud Rotary -1 Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth -2A) ft Excavation �14_in diameter Open Bottom xGravel Pack/Gravel Size in diameter <br /> Conductor Casing In diameter / Conductor Casing Depth it <br /> Well Casing Diameter In Thickness/Gauge/ASTM Soled VAkv _ Steel Plastic Stainless Steel Other <br /> Grout Seal Depth C>(,, ft _. Neat Cement(94 lb bag/5-10 gal water) x Sand Cement sack mlxr7 gal water I <br /> Bentonite(20%solids) _ Other <br /> Grout Placement Method Pumped _Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By '�-Dnller Pump Contractor, _ Other <br /> nConcrete Pedestal Dimensions:Width 7 ft Length S ft Thickin Chrtsty Box Stove Pipe <br /> PUMP X Submer%t le- Turbine - Other HP Pump Set -C ft Standing Water Level <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 /> MINIMPM 24 H YR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)963-7697 <br /> SIGNED TITLE `� (C I� C-`7 DATE <br /> AOL <br /> - I I- <br /> ' <br /> it <br /> ;r o <br /> 21 <br /> h <br /> - <br /> 2 0 <br /> DEPARTMENT US ONLY 77' <br /> 57 <br /> Application Accepted By Date Ares CA[k ._ Employee IDI <br /> Grout Inspection By - ` ' Date 3 SPECIAL Well Permit <br /> Pump In Br -G Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth�����0 <br /> COMMENTS (� <br /> PE SC Received Amount Dsb Service R tU ost s _-- Invoice M Well ` J�O�� J -( <br /> Codes ktfo B Rett so �(j�Q RC1 <br /> It ?) c �oPt�OvQP <br /> t <br /> EHO 43-M WELIR'UMP PER !P� <br /> 470'2 <br />