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1-1\44A 0�111— <br /> WEI_LIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZFLTON AVENUE-STOCKTON CA 95205-(7119)468-3420 <br /> NON-REFUNDAI3L PERMITCALL 299 953-7697 FOR INSPECTIONS EXPIRES t Y DATE ISSUED <br /> l � J09ADDRESS ' Or�/V`' o c//1��on`�r2 Cm.. 1 0 L� 61 ma <br /> CROSS STREET (V APIN p O V �+ PARCEL SUE W)D SE AP�ICATION# �`1 A <br /> OWNER NAME VA 7 fi r�l l J y PHONE 1J r r��r / .-fr <br /> OWNER ADDRESS` 1� "• • VA r '� /ST.--. / (A C� .J 3 <br /> 125 <br /> CONTRACTOR _ Fri( Ir e n 1411 ( � P...CONTRACTOR ADDRESS �r _ l94 <br /> v+ C f T <br /> 1i _ <br /> SUBCONTRACTOR IV/,ft PRONE _ <br /> SUBCONTRACTOR ADORE�63 ! f CRYISTATEIZIP it tl�Il` 11.7 <br /> LICENSE C-57 V C-61 D-09 Other NUMBER ExraRAnoN DAre <br /> GEOGRAPHICAL INFO ATION: Coordinates X Y Township_ Ran®e Section_ v <br /> i INTENDED USF V DOmeSIiC/PrVatR IrrigatiorlAgricultural Industrial Water Quaiity Monitoring Soil Sampling/Characterization <br /> j Public Water System <br /> If different from Owner waier Sysurn r4mme ConteCt Name w Phone Number <br /> TYPE_QF WORK NowWell Replacement WeII Well NteratiDNMGdfiption Other <br /> MonitoringWeil(s) #of wells SoilBoring(s) aorbpdngs Geotechnical xorbonng. <br /> Out-pi-SeMc W Out-Cit-Service Well Renewal Cross-Connection Repair r--. <br /> New Pum V—Pum2 Re acement Pump Repair Raise Well Casing, <br /> WELL CONSTRUCTION �L <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other C� <br /> Proposed Well Depth ft Excavation in diameter Oper Bottom -Gravel PacklGravel Size in diameter h <br /> Conductor Casing _ in diameter J Conductor Easing Depth ft <br /> Well Casing Diameter_in ThicknessiGauga/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb begr5-10 gal Warary Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant f Accelerator(name) <br /> PEDESTAL Installed By Onli'er Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Len4h ft Thick in Christy Box Stove Pipe <br /> PUMP V Submersible Turbine Other HPJ Pump Set ft Standing Water Leyad 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 LA <br /> MINIIuIU4 H AD E NOTICE REQUIRED FQINNSPE�C/TIONSS-PLEASE CALL(20911-95a-7697 <br /> SIGNED TITLE_" / V/i. If * ! E 00 DATE <br /> V 1 <br /> 1 7— <br /> CEPA <br /> GJv <br /> V <br /> Li <br /> QaYM'� x, 2016 <br /> RECEry <br /> RON'1.4ENTAL HEALTH <br /> s�� Q ERIIhITI £RU?CES <br /> F.iv4RCN . <br /> ur:a,rupEPARTv� P TMEN7 U$E ,rOyLY <br /> Application Accepted By 'I U Date / Aram,_ Frrplpyoe kD# 4� <br /> Grout Inspection By Date _... SPECIAL Weil Permit <br /> Pump Inspec ion By Date WAIVER Received <br /> Soil Bening inspection By Date Conettucted Well Depth ft <br /> COMMENTS <br /> PE Sc Received het Amount Permit! Mvolcell Well ID# <br /> I Codes Info B Remitted Gate Service R uest# <br /> F.H7---1E WELL(PUMP PERM{T <br /> <r30,2 <br />