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1 <br /> 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 70$ r1EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS `7 E. /�E`T/G� (Z�. CrrY21P A AMPO 7SZ20 ppp� <br /> m r� <br /> CROSS STREET_J5 4WS?L^ /`—P• APN COS— — " —� PARCEL SIZE �LAND USE APPLICATION# m tyj <br /> OWNER NAME N1jN1+G ms PHONE 12041 .6-7 ��G Y •"- "�� <br /> OWNER ADORESS ',G$�J F+ %>Ot LJ r1AF4L tZ • CITY/STATE21P t464^P <br /> O eA 47-T-7-72,4k <br /> A` <br /> CONTRACTOR & D• � •"�`,� 4 ,4530e—. , /�C' PHONE�Za4) 3b7- <br /> CONTRACTOR ADDRESS 7C,Z 11(40 L(S T/h/4'L CRY/STATEMP GQ//► (r/1 7� •O <br /> Q/ <br /> SUBCONTRACTOR /� I � ,�I PHONE <br /> SUBCONTRACTOR ADDRESS CnY/STATEZP <br /> LICENSE xC-57 C-61 D-09 Other NUMBER 469oO EXPIRATIONDATE DK 1z A <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE D DOmestiC/Private -Irrigation/Agricultural - Industrial -Water Quality Monitoring Soil SamplinglCharaclerization <br /> L Public Water System <br /> N diff—t from Owner a ar ys am ame Cmlarn ame or —NUMDef <br /> TYPE OF WORK D New Well J Replacement Well D Well Alteration/Modification Other <br /> F Monitoring Well(s) #ofwells DSollBoring(s) korbowgs kGeotechnical-1M ofbcrings <br /> r-Out-Of-service Well D Out-Of-Service Well Renewal I Cross-Connection Repair <br /> C New Pump I i Pump Replacement D Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _ Mud Rotary r Air Rotary 4 Auger i Cable Tool Push Point Other 01 <br /> N <br /> Proposed Well DepthSw'l.!r ft Excavation �O in diameter ,..Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diamoter_in Thidmess/Gauge/ASTM Schad Steel i 1 Plastic I Stainless Steel Other <br /> Grout Seal Depth ft I Neat Cement(94 Ib bag15-10 gal water) LI Sand Cement sack mix17 gal water <br /> Bentonite(201/6 solids) 'A Other 1 L A1&J /G (�;IJ. (F W. U3 �✓TO �j <br /> Grout Placement Method r Pumped Free Fall - Other I Retardant I Accelerator(name) <br /> PEDESTAL Installed By 1-'I Driller :1 Pump Contractor _ Other <br /> Concrete Pedestal Dimensions:Width R Length ft Thick in L Christy Box I Stove Pipe (71F,1 <br /> PUMP Submersible i Turbine Other HP Pump Set ft Standing Water Level it h <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN ` I <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS �l <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> — r- MINIM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED Lam/ TITLE ST�`'� Er/G/NEE� DATES S 12- *`�` <br /> 6- . <br /> PAYMENT <br /> RECEIVED <br /> F= 41AR 0 5 2012 <br /> 14 JOAQuo, <br /> pWR0NYEWTAL <br /> I� T <br /> EPARTMENT USE ONLY C <br /> Application Accepted By DateS Area Employee ID, <br /> Grout Inspection By Date SPECIAL WBII Permit <br /> Pump Inspection Date WAIVER Received <br /> Soil Boring on Date �4-' ,Ij� Constructed Well Depth ft <br /> COMMENTS Ins ti _ — G 7 <br /> PE SC Received CCheckiI Amount PermiU <br /> Codes Info By Remitted Date Service Request# Invoice# Well ID# <br /> 437-1- <br /> END <br /> 37 END 43�06 WELL(PUMP PERMIT <br /> eA4M <br />