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WELL/PUMP PERMIT <br /> SAN Jr1ADUIh COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 -(209)466-3120 <br /> NON-REFUNDABLE PERMITCALL 1209]9.5_3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �. S fir' <br /> JOB ADDRESS /2 AMC CITY21P <br /> s � _ & / <br /> CROSS STREET r APN PARCEL SIZE LAND USE APPLICATION# <br /> 4// E J ''/ <br /> OWNER NAME rf[ _ _ PHONE-'>4' I - L7 <br /> OWNER ADDRESS /w _ CITY/STATE/ZAP <br /> CONTRACTOR PHONE'?,—j 7_V 7✓� <br /> - . <br /> (CONTRACTOR ADDRESS _ __ CITY/STATE/ZIP <br /> (SUBCONTRACTOR _ _____ _-_ _ PHONE _ <br /> (SUBCONTRACTTOrR ADORESS ____ _.. _ CIN/STATEJZIP <br /> LICENSE KC-57 C-61 D-09 Other NUMBER?3 v_ EMRATION DATE 6-13 <br /> J <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Ranga Section_ <br /> INTENDED USE mestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> It different from Owner Water 5y5terh Nam Contact Narne or Phone Number <br /> TYPE OF WORK yQJew Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bonng(s)___ a nt bomgs Geotechnical n of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> >*ew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION I <br /> Drilling Methods Mud R ry Air Rotary Auger Cable Tool Push Point Other I <br /> Proposed Well Depth ft Excavation�L n diameter Open Bottom )GGravel Pack/Gravel Size__in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter Cin Thichness)Gauge/ASTM SCherLM Steel lastic Stainless St Other <br /> Grout Seal Depth 7__ft Neat Cement(94 Ib bag15-10 gal water) /e$and Cement , _-_sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method,Aeumped Free Fall Other Retardant I Accelerator(name) _ I <br /> IftnEIT& Installed By 5CDnller J Pump Contractor Other <br /> I Concrete Pedestal Dimensions.Width ft Length It Thick in Christy Box Stove Pipe <br /> PUMP 746ubmersible Turbine Other. HP Pump Set——Y-7 ft Standing Water Level It <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. 1 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 /> ���y4•L/, A�7l�u';1_INI MUM 24 HOUR ADVANCE NOTICE REQUIRED F(�(1{,�,'�INSPECTIONS <br /> SIGNED /f.�L.�CJ) ///L19� TITLE QC AYL�'F YI. �lN'J C fSr� DATE ��D`L L •� <br /> 61 A <br /> I <br /> I / <br /> r ' <br /> A <br /> c ' <br /> 3 <br /> �O G L- <br /> =ul T, <br /> EP TMENT USE ONLY GigT[ T <br /> Application Accepted B Date 1 /1q/ 12— Area Employee ID#C7-/ T�/ <br /> Grout Inspection - Date L / SPECIAL Well Permit <br /> Pump Inspecti + Date WAIVER Received <br /> Soil Boring Inspection ey Date Constructed Well Depth ft <br /> COMMENTSt <br /> PE SC Received Ch Amount Date Permit/ Invoice# Well IDN <br /> Codes �Info By_ -ash Remitted Service Request# <br /> 'C ; l � a rt �l /9 <br /> EHD 47-ue WELL%PUMP::A <br /> SrD4'08 <br /> \. <br />