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/M--/"o WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> IJOB ADDRESS .% CITYIZIP �JOVI ' 1 r m <br /> ML <br /> CROSS STREET N © •PARCEL SIZE �a LAND USE APPLICA ION# <br /> N <br /> PHONEo <br /> - <br /> OWNER NAME (/` <br /> OWNER ADDRESS / O o a-Je �'1 r4a. CITVISTATEIZIP ! <br /> CONTRACTOR GL M C I PHONE _L-"- <br /> CONTRACTOR ADDRESS ✓� CITY/STATEIZIP <br /> SUBCONTRACTOR PHONE I <br /> 1 <br /> SUBCONTRACTOR ADDRESS_ CITYISTATEIZIP <br /> LICENSE XC-57 C-61 C 0-09 J Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private Irtlgatlon/Agricultural G Industrial ❑Water Quality Monitoring �J Soil Sampling/Characterization <br /> G ublic Water System <br /> www,,,���If dAereM from Owner y em ame 0 amc or PFione Number <br /> TYPE OF WORK yt'rvew Well L Replacement Well n Well Alteration/Modification �7 Other <br /> ' \MonitoringWell(s) #of wells DSoilBoring(s) sof bormgs I Geotechnical Ao+bodng, <br /> C <br /> C Out-Of-Service Well D Out-Of-Service Well Renewal U Cross-Connection Repair <br /> f New Pump L Pump Replacement rl Pump Repair o Raise Well Casing _ <br /> WELL CONSTRUCTION <br /> Drilling MethodMud Ro�Jta�/�F Air Rotary "l Auger G Cable Tool 7 Push Point C Other V� <br /> Proposed Well Depth CSE++�R Excavation Z-Z in diameter G Open Bottom ravel Pack/Gravel Size in diameter <br /> L Conductor�asing in d ameter ! Conductor Casing Depth h <br /> Well Casing Diameter yin Thickness/Gauge/ASTM Schad I i Steel lastic C Stainless Steel L Other Z <br /> Grout Seal Depth C/ It Neat Cement(941b bagl5-10 gal water) O and Cement sack mix/7 gal water <br /> KlIentonite(20%solids) Other <br /> Grout PIacementt Moth Pumped J Free Fall ,I Other I,Retardant I Acoelerator(name) <br /> PEDESTAL Installed By C Drillerump Contractor O Other I` <br /> I Concrete Pedestal Dlmens One,Width It Length R Thick in I-Christy Box n Stove Pipe <br /> PuMP Sibmersible7 Turbine C Other HP Pump Set; ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED TM 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 CAI IFORNU CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM N COMPLIANCE WITH ALL <br /> -WORKERS COMPENSATION LAWS. <br /> t UM Z4 IR ADVANCE NOTIC RE� FOR INSPECTIONS / 7 <br /> SIGNED JG Trna / alt DATE <br /> � _ I <br /> / - , <br /> I <br /> JWA . <br /> I - <br /> TDEPART.KUSE-ONLY_;+s-«y.+.� .•• <br /> Application Accepted By Date �0 Area Employee ID# � <br /> Grout inspectionDate�Z� /� 'I SPECIAL Well Permit <br /> Pump Inspection By Date L WAIVER Received <br /> Sal Boring Inspection By _- Date Constructed Well Depth ft <br /> COMMENTS NOT A.) F- <br /> r nil ��J A&L•_--/n� <br /> PE SC Recelvad Check#/ ery <br /> Amount Date I Pe—quest <br /> Invol"0 Well ID# <br /> Info <br /> Codes B Remitted Sice <br /> Re oast# <br /> EHD 4306 WELL[PUMP PERMIT <br /> BN4 D8 , <br />