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cff7 IVB+ 7- <br /> WELL/PUMP <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS V 0 FS �� L n, _ CITY2IPs�CL, G P qSLrz mh H <br /> RLio <br /> CROSS STbra APN PARCEL SIZE2�LANO <br /> USE APPLICATION# <br /> Jj I <br /> OWNER NAME )S�l 2�riAd�rT/ �L67 Mr'!l1��/- 1 PHONE '-G 1 -�1 fl'-�{-OZ3 <br /> L- <br /> OWNER ADDRESS �OT !V5 Jf�i G/1 C,i�3n Sa'=.(� CITY/STATE/ZIP 1 IjPn C-4 LI <br /> ,C1z3 <br /> 6 <br /> CONTRACTOR PHONE 7-Oq 3 ZU <br /> J <br /> CONTRACTOR ADDRESS qUZlni,jra <br /> CITY/STATE/ZIP L•CL &,4/�/y/S/ <br /> SUBCONTRACTOR ! /�/1 PHONE �1A/ 7 <br /> SUBCONTRACTOR ADDRESS r✓ CITYISTATEIZIP / // 1 <br /> LICENSE C-57 C-61 D-09 Other NUMBER O `` <br /> EXPIRATION DATE //�!/ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private IrTlgation/Agricuftural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: water bystern Name LonlaCt Name or Phone NUMber <br /> TYPE OF WORK New Well Replacement Well Well AlteratiorVModiflcation Other <br /> Monitoring Well(s)_ #of wells Soil Boring(s) C of bonngs ){Geotechnical M or bo ings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION p IFN <br /> Drilling Method Mud Rotary Air Rotary '(Auger Cable Tool Push Point Other •e/ <br /> Proposed Well DepthIt Excavation in diameter Open Bottom Gravel Pack/Gravel Size In dtam <br /> id <br /> Conductor Casing in diameter I Conductor Casing Depth It 92016 <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel S.% <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement E 11(mmili <br /> Bentonite(20%solids) I(Other <br /> Sc•II cHxttfftUt_t� At <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length It Thick In Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It Standing Water Level ft <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 /> MINIM HOU(Rp A NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED LH TITLE G2'GfCc{/NIZ4( deoDATE 1• <br /> I <br /> F[ EFE <br /> I <br /> i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By 2vDate y l`- lv Area YJ / Employee ID# _FSCc��D <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By .Date ❑ WAIVER Received <br /> Soil Boring Inspection 8 3 Date 3 — -1.w Constructed Well Depth ft <br /> COMMENTS <br /> 7!!5-uG�t-�c� ��arCtn7s <br /> PE SC Received hec Amount Date PemnIU Invoice# Well ID# <br /> Codes Info B ash Remitted Service Re uest# <br /> 3•7 IED ala � ��.ov z-19-16 SIZE ��1?N <br /> EHD 0.108 WELL/PUMP PERMrT <br /> 4rdW12 <br />