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• ate.. <br />NNTLL / P[JiViP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 31" FL- STOCKTON CA 95202 - (209) 468-3420 <br />PERMIT CALL (209) 993-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS V3 O o 1A clt P—/,— CIITTYIZIP_ ` 6E /i't'L-f e !/ <br />CROSS STREET ( /v/f % APN _f%�PARCEL SIZET) T- LAND USE APPLICATION # /% <br />OWNERNAME I,V T PHONE X"]/ 4[ l� <br />�} r <br />OWNERADDRESS L k ,2 / / 1 , CITY/STATF/ZIP '}-�[� <br />CONTRACTOR rAj--ACJ{ /,(��1� JJ �rL.L � ` ` �"i /[PHHOONEE 773 ` � 7 ZS, <br />CONTRACTOR ADDRESS r V RJ � I CITY/STATVZIP/ - L- <br />ADDRESS <br />CITY/STATE/ZIP <br />PHONE <br />'>< 57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE -%<15omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: -, Syv.. Name nucr un ar Ph— N..bzr <br />TYPE OF WO ew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) <br />s of borings ❑ Geotechnical s of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />'*04ew Pump ❑ Pump Replacement ❑ Pump Repair <br />Date <br />WELLCONSTRUCTION <br />Drilling Method,*Mud gotary ❑ Air Rotary ❑ Auger ❑ Cable Tool <br />❑ Push Point ❑ Other <br />Proposed Well Depth% ft Excava6on_/L- in diameter <br />❑ Open Bottom 1-4131bravel Pack / Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 4 in Thickness/Gauge/ASTM Sched YO <br />❑ Steel J61Plastic ❑ StainI Stec1 ❑ Other <br />-d <br />Grout Seal Depth �' ft ❑Neat Cement (94 !h bag/S-lOgul water) <br />$Sand Cement sack mix / 7 gal water <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % <br />Name Specs n File ❑ Specs Submitted <br />Grout Placement Method-AWPumped ❑ Free Fall ❑ Other <br />❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By '. Driller ❑Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length <br />ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP 54isubmersible ❑ Turbine ❑ Other HP <br />Pump Set ft 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. 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 />Application Accepted Date Zb Area EmployeelD#�� <br />Grout Inspection B lei Date �S/�7l ❑ SPECIAL Well Permit <br />Pump Inspection By 7T Date �!-//nG ❑ WAIVER Received <br />Constructed Well Depth ft <br />COMMENTS ,nA) 1,0K I=- AQ /n <br />7f7 <br />PE SC <br />Codes Info <br />Received <br />B <br />Checlt#/ <br />Amount <br />emitted <br />Date <br />Permltl <br />Service Request # Invoice # Well ID# <br />Leff z � s 12 <br />EHD 43-02-006 ,j L fL-_.r-, <br />Q/ <br />J' r(]/\ 0' WELL PUMP PER.NIT <br />1:228005 `-�( � <br />