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WELUPUMP PERMIT <br /> SAN JOActum COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CAS5205•(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �) y I C w <br /> .JOB ADDRESS 1454 C l,.t r Y Ay CwyjzIP L c� q <br /> �t 1 � (� <br /> CROSS STREET 1--- -L. - Cljj 1 IAPN�V 1 ©�f D�ARCEL SIZE LAND U E PLICATION A /'� m <br /> LJ n Y"I K o L7 1--� 4 i I'l PHONE js u <br /> OWNER NAME r_ y l e 2470 �r� �)�t <br /> OWNER ADDRESS I =l 1 1�tit r r j �/e- Crry/STATEILP��'t%A 1 I^�c rAy �j 7�(`� 0 <br /> CONTRACTOR T1'�1 y I {�/� rPHONE Jc,q ' '�+-7 7(`l� <br /> 52 <br /> CONTRACTOR ADDRESS�I' I) J� '^7 c74 CITYISTATEIZIP G A 1 CA <br /> �� `� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> ��II2p� _ I <br /> LICENSE C-57 Ca61 �!D-09 L Othef NUMBER�TCI'1 )O� + <br /> EXPIRATION DATE J i --` <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE ,XDomesticaPrivate ❑Irrigation/Agricultural :i Industrial _i Water Quality Monitoring C Soil SamplinglCharactedzatlon <br /> Public Water System <br /> Iidifrerent ham Owrer: <br /> n.er Uontad Nam of Fhane. u <br /> DU <br /> TYPE OF WORK `(, New We$l Replacement Wel !--Well AlterationlModification a Other <br /> A Monitoring Well(s' #of weFS L Soil Boring(s) a of wonus Geotechnical a of borings <br /> Oul-Of-Service Well F- Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump ❑Pump Replace enj L Pump Repair :Raise Well Casing <br /> W ELL CDNSTRUCTION <br /> Drilling Method Xr Mud Rotary f Air Rotary Auger Cable Tool r Push Point Other <br /> Proposed Well Depth 3 G N Excavation _in diameter 7 Open Bottom )(Gravel PaWGravel Size114'' —in diameter <br /> Conductor_Casing in diameter I Conductor Casing Depth ft <br /> WeII Casing Diameter C) in ThlrlmesslGaugeIASTM SchedLULtlt_44) Steel >f Plastic Stainless Steel -:Other <br /> Grout Seal Depth �C() --f1 L Neat Cement(941b bag!&iD gat waled fid.Sand Cement 1(1.; sack mW7 gal water <br /> Bentonite(20%solids) a Other <br /> Grout Placement Method`A Pumped _ Free Fall a Other L'Retardant 1 Accelerator(name) <br /> E920M Installed By X Driller !i Pump Contractor Other <br /> Concrete edestal nDimensions:Width 5_ft Length___2_ft Thick n n Christy Bax L!Stove Pipa <br /> PUMP Submersible- Turbine Other HP_Gr Pump Set Fl Standing Water Level qf' ft <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. 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 /> MINIM MM�24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASSE CALL(209)963-7697 <br /> 7 1 <br /> SIGNED_ S'r-�^C �C71LrZLe`L TITLE �� C 1 rC•7 rA en I DATE <br /> pAYME - <br /> REcEvv El r <br /> ,IUM 13 <br /> 6µJOAQUFk u <br /> EHVI RON <br /> HEAD DE <br /> DIEPAffiTMENT U E NLY <br /> Application Accepted Date Area 44 R� Employee l D# �O <br /> Grout Inspection By Dale -1 SPECIAL Well Permit <br /> Pump Inspection By Date .1 WAIVER Recelved <br /> Soil Boring inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#! Amount PermiU Invoice# Well ID# <br /> Codes Info B Cash Remitted Date Service Re uest# <br /> rQ� ° d�jl�f lv Sa�50y5 <br /> WELL IPL'MPFEnMIT <br /> EMD 47 ,T� /Li 1i Ly/ <br /> 413CI52 11Y /T f /I� <br />