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WELL/PUMP PERMIT <br /> �60 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)465-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> LA <br /> /V• Si (r �� I � C m <br /> JOB ADDRESS CITY/ZJP 1 J(:��1)r) <br /> r 9 i O <br /> CROSS STREET G- �T/2l D Cie) J' J APN Ta?—,g{O- PARCEL SIZE I 0 LAND USE APPLICATION# in <br /> p <br /> OWNER NAME Siv.Gl Y7 �11.'�f (] 17(lI LLI II)'� C 1--G,/�Z_(,'l r�� rn <br /> R' PHONE r �a (L/ <br /> OWNER ADDRESS SctiYne- CITYISTATE21P -5 Cl l'ir" , <br /> CONTRACTOR ZZ2 l).o^e, ,n an, J 0 aY e e-/ Sy sl,� (PHONE_ 1 3 I -- <br /> -1() <br /> ,n1 <br /> CONTRACTOR ADDRESS�-{J W 11/[L)X �[Y CRY/STATEMP 'J''e C&;,'1.CTI <br /> d _7 1—r <br /> SUBCONTRACTOR ~� 'IM /J J�(j/)I. 1 /� PHONE <br /> ` IAV /-L'5,)L-735-1 <br /> SUBCONTRACTOR ADDRESS I -71611 3 L T I 1 l'[' A//4 CRYY//STATEZP S 1 a�-�-'1 J n ,CA `P -J,�, <br /> LICENSE C-57 C-61 D-09 Other NUMBER 3 4 7 EXPIRATION DATE �� 1 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE )9-Domestic/Private Irrigation/Agricullural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or one um er <br /> TYPE OF WORK New Well �(,Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #Of Wells Soil Boring(s) #of borings Geotechnicai #of borings <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 <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other t <br /> Proposed Well Depth '�iic� ft Excavation t Z in diameter Open Bottom xGraveI Pack/Gravel Size /w i in diameter <br /> Conductor Casing — in diameter ! Con uctor Casing Depth ft <br /> Well CasingDiameter <br /> in Thickness/Gauge/ASTM Sche i Steel )&,Plastic Stainless Steel Other <br /> Grout Seal D2pthj4Z ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method,-"Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP jC Submersible Turbine Other HP 2-. Pump Set 2.7 0 It Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 /> MINIMUM 24 HOUR AD E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76 7- <br /> SIGNED ,�- TITLE C1 J�h�•� <br /> DATE <br /> i <br /> 11111 IT-= <br /> - d RF Y ENT <br /> CES y—p <br /> DEC 6 2416 <br /> NVIROV rN CO(/N <br /> lTI p�A TAt <br /> �. <br /> -LL-Li 11 <br /> 1 <br /> EPA TMENT USE ONLY <br /> Application Accepted - Date41 <br /> Area_L�-I l Employee I Dtt <br /> Grout Inspectioriby ' i CC - Date ❑ SPECIAL Well Permit <br /> Pump Inspection By I y ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#1 Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By_ —I Cash Remitted Service Request# <br /> .01 S�zl. <br /> Z �C <br /> EMD 12-06 <br /> /12 <br /> 3/30WELL/PUMP PERMIT <br />