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Z'~ 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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> /6-:3(,C) CI <br /> �o}C NLZIP -G Jr / 7 o m <br /> JOB ADDRESS <br /> D <br /> CROSS STREET f6'1 / APN 0!51—Zoo-op PARCEL SIZE /LAND USE APPPurATION# <br /> OWNER NAME PHONE / <br /> OWNER ADDRESS M '-rtrL CITYISTATFJZIP LG r M& C-S,)Yo <br /> CONTRACTOR I"l li p'"�Cv'�r11I (/V(i�F-L� �5,.S I.1-1 PHONE /pJ tt-7;1�(� <br /> CONTRACTOR ADDRESS �r�O �N�'Cak CITYISTATEIZIP '4-LAI"LJiJ H•r 9!` S' <br /> M <br /> SUBCONTRACTOR / -( r ✓• �[ ��{�JAi (O�j-Z� PHONE <br /> SUBCONTRACTOR ADDRESS Ai 6i-:j CITYISTTATTEIZI/P !('l t,�{fib 4 - —T <br /> LICENSE 45C-57 L C-61 J D-09 fl Other NUMBER, 63 O. O ExPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> ! INTENDED USE D Domestic/Private 4Inigation/Agricultural C Industrial ❑Water Quality Monitoring D Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner Water byerrl Name (;OntaCt Name or ne NUMDer <br /> TYPE OF WORK #New Well C Replacement Well D Well Alteration/Modification C Other <br /> 7 Monitoring Well(s) #of wells ❑Soil Bonng(s) 4 of bonngs ❑ Geotechnical z of borings <br /> 7 Out-0f-Service Well ❑Out-Of-Service Well Renewal F- Cross-Connection Repair <br /> New Pump F PLjm2 Replacement D Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method f Mud ry C Air Rotary 7 Auger ❑ Cable Tool 7 Push Point _1 Other <br /> Proposed Well Depth ft Excavation/in diameter -1 Open Bottom QGravel Pack/Gravel Size in diameter <br /> U Conductor Casing ---- in diameter / Conductor Casing Depth --- ft <br /> Well Casing Diameterg__in Thickness/Gauge/ASTM Sched L u Steel fj Plastic 'Stainless Steel C Other <br /> Grout Seal Depth It C Neat Cement(94!b bag/5-10 gal water) C Sand Cement sack mixt gal water <br /> )OBentonite(20%solids) L Other <br /> Grout Placement Method &umped ❑ Free Fall D Other _1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller )QPump Contractor C Other Z <br /> L Concrete Pedestal Dimensions:Width�it Length--�ft Thick in U Christy Box D Stove Pipe <br /> PUMP P Submersible Li Turbine D Other HP Pump Set fl Standing Water Level R <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. t 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 /> MINI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTI S-PLEASE CALL(209)953-/7697 <br /> SIGNED TITLE DATE <br /> i ' <br /> i <br /> ' 9 <br /> G A <br /> h <br /> EP VI <br /> — _ I "zAi1HDE1AFjMrNt III <br /> JA I <br /> _l t <br /> 5 <br /> ;?e( — )75Je-iffy 310 O N L Y <br /> a ,J7. - - - .:—�.;:�-:..�. - -�a.�:�-x.�•� � .,g_--?'pplication Accepted By Date L Area Employee ID# S 9 tF SF C, <br /> I Grout Inspection By Date /_ l -I SPECIAL Well Permit <br /> Pump inspection B - Date -1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info <br /> By Service Request# <br /> ¢3ln9 [g r7 O $ !t34f- srxoolo2 z 59 <br /> �F3s;"a OSo I X53. ��Ob X72-G1� <br /> EHD 4306 WELL(PUMP PERMIT <br /> W6/09 <br />