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WELUPUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE JPERMIT CALL 209)953-`76197 FOR <br />%INSPECTIONS EXPIRES 1 YEAR FROUMJ DATE ISSUED <br />JOB ADDRESS J. �I % 9 , Co OA L �f)%jU UL O w /`�`� CITY/ZIP _ ) /ter 7 <br />CROSS STREET !i , (��%Yj� �{� APN Y� �3 -0^9-d <br />O^9-0 � PARCEL SIZE C/� LAND USE APPLICATION # <br />OWNER NAME yj, ?I/,7/1 1 J/ U ��i►7/ �. !ter PHONE <br />r <br />OWNER ADDRESS ��UV <br />Y V /" �`✓) ' ) /t'I�'I "� 1jV CITY/STATE/ZIP I &/"1__ <br />CONTRACTOR <br />yj44 Gt� I-t�P.J I PHONE _!ZS D / D66" <br />CONTRACTOR ADDRESS JLS�l CITY/STATE/ZIP <br />SUBCONTRACTOR _ PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE C-57 C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y_ Township __ Range Section <br />INTENDED USE Domestic/Private )( Irrigation/Agricultural ❑ Industrial �t ?'Q c�j�ll�l� EM'FlIation <br />❑ Public Water System _ e I�n[#��\�[/j� K <br />If different from Owner: Water System Name •mw•orrif 4aarA4Por F7�o11e IFAI fflmw <br />TYPE OF WORK ew Well Replacement Well ❑ Well Alteration/Modific tangy r� wile G(�re Wil u <br />❑ Monitoring Well(s) # of wells I Soil Boring(s) ((� gL`OTr1j1�fli!#� +� # of borings <br />Out -Of -Service Well I Out -Of -Service Well R�raQyr�,�l s -CQ f�p�tr,IVlseOn <br />New Pum -1 Pump Replacement l Pum Repair <br />yy [[���� <br />WELL CONSTRUCTION <br />Drilling Method t Mud Fj6ta.ry ❑ Air Rotary Auger Li Cable Tool Push Point Other <br />Proposed Well Depth v ft Excavatio / t in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / ConductorCasingDepth ft <br />Well Casing Diameter / D in Thickness/Gauge/ASTM Sched ` _,2.6 � Steel Plastic ❑ Stainless Steel Other <br />Grout Seal Depth_ 2 0U) It Neat Cement (94 Ib bag/5-10 gal water) ] Sand Cement /0 - sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method 4 Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />i Concrete Pedestal Dimensions: Width ft Length It Thick in Christy Box Stove Pipe <br />PUMP ❑ Submersible Turbine Other HP Pump Set ft Standing Water Level 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 />r <br />m <br />D <br />0 <br />v <br />m <br />m <br />DEPARTMENT USE ONLY _ <br />Application Accepted By Date v k Employee ID# <br />Grout Inspection By Date ❑ SPECI L Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS „uA t <br />Date Constructed Well Depth ft <br />; B Ott \ 1 a <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check#/ <br />as <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />