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®� WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> En <br /> JOB ADDRESS b0it / 6,u 1` � CITY/ZIP LCITf� / SZ D <br /> _ ^ o <br /> CROSS STREET _ �� APN U 6�T� <br /> PARCEL SIZE LAND USE APPLICATION# m <br /> ��l11`�g 6 N <br /> OWNER NAME p[L/� PHONE <br /> Q <br /> me— <br /> OWNER ADDRESS Aea '��D CITY/STATE/ZIP <br /> CONTRACTOR //1�9I��� PHONE 513/ Zeal <br /> CONTRACTOR ADDRESS 6l : 1'�/&Atm, f CITY/STATEIZIP <br /> SUUBCONTRACTOR / ' 1 •�/i�I I (( PHONE <br /> f <br /> SUBCONTRACTOR ADDRESS �OYGy . of V(W(oY F� CITyY//'SSTTIATE/ZIP <br /> LICENSE W C-57 -61 , D-09 Other NUMBER y�� w i EXPIRATION DATE-. <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_. <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Xndustrial i Water Quality Monitoring i Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK yNew Well Replacement Well - Well Alteration/Modification - Other <br /> Monitoring Well(s) It of wells Soil Boring(s) Rof borings Geotechnical It 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 CONSTRUdION <br /> Drilling MethodIvlud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 2—& ft Excavation _4_ in diameter Open Bottom 4Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> —W <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad /fin Steel %elastic StainlessSteel I Other <br /> Grout Seal Depth /60 - Neat Cement(94 Ib bao-10 gal water) /_Sand Cement sack mbd7 gal water <br /> i Bentonite(20%solids) ` Other <br /> Grout Placement Method Pumped Free Fall ❑ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller - Pump Contractor i I Other <br /> I � Concrete Pedestal Dimensions:Width ft Length ft Thick in I Christy Box - Stove Pipe <br /> PUMP Submersible Turbine Other HP� Pump Set­_,jT�ft Standing Water Level ti ft <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 /> MINI�R CE N'OATI�CE REQUIRED FOR IN <br /> �E�CTIONS- PLEASE CALL(209)95?-769 <br /> SIGNED VT'6+' TITLE L - DATE,,,7 / <br /> e <br /> 1 <br /> -T Tllqt�- <br /> DEP RTMENTS�l) E/ONLY <br /> Application Accepted C Date /3 // Area Employee IDIS <br /> Groot Inspection B/ Date 'Z ❑ SPECIAL Well Permit <br /> Pump Inspec� Date� ❑ WAIVER Received <br /> Soil Boring Inspection B Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received ec Amount Date Permit( Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> b �ka�g e° 3 ►s o� � ' Pb 7�1 <br /> EHD 13-06 WELL/PUMP PERMIT <br /> 4/3011:; <br />