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T-A4 S Lw_) <br /> WELUPUMP PERMIT <br /> Se.N JOA.OI:'4N 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 /> JOB ADDRESS -- CITY/ZIpP-Cj�l / o <br /> CROSSSTREET APN� ✓&A AID <br /> PARCEL SIZE 1 LAND USE APPLICATION# A <br /> OWNER NAME �� y� � _ V ___—. PHONE <br /> OWNER ADDRESS to gd- CITY/STATE/ZIP_�//✓ 70'k 52 5_Z1 Z- <br /> n / —T� - 7 <br /> CONTRACTOR /A �`//7G fin/ 6, ICL •� PHONEZ 7/Z Zj75-7 <br /> CONTRACTOR ADDRESS (U �L�C'�j/I�Ulll/ �� �G� CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 I C-61 i D-09 [1 Other NUMBER. / EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range__ Section---- <br /> INTENDED USE NDomestic/Private C Irrigation/Agricultural ri Industrial Ci Water Quality Monitoring [i Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: WeI tem ame contact Name or Phone Number <br /> TYPE OF WORK X New Well Replacement Well G Well Alteration/Modification CI Other <br /> Monitoring Well(s) #of wells L; Soil Boring(s) #of borings Geotechnical of borings <br /> 1 Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump Pump Replacement ❑ Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 9 Mud Rotary I l Air Rotary ; Auger Ll Cable Tool LI Push Point 0 Other <br /> Proposed Well Depthft Excavation 1/ <br /> / p <br /> in diameter ❑ Oen Bottom i` Gravel Pack/Gravel Size b" in diameter <br /> H Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 10— in Thickness/Gauge/ASTM Sched C;_X Z/-_ 'j Steel Vf Plastic ❑ Stainless Steel ❑ Other_ <br /> Grout Seal Depths ft Neat Cement(94 Ib bag/5-10 gal water) td Sand Cement lLJ-,3 sack mix/7 gal water <br /> I Bentonite(20%solids) �I Other <br /> Grout Placement Method Pumped Free Fall = Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ?F-Driller Pump Contractor LI Other <br /> Concrete Pedestal I-Dimensions:Width ft Length ft Thick in Fi Christy Box r Stove Pipe <br /> PUMP h Submersible r' Turbine I; Other HP L Pump Set ,�/,L% ft Standing Water Level1-2 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM HOUR ADVANCf.�TICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE ��1���� DATE _ "//7 <br /> J <br /> IV <br /> 1 14 <br /> 4A L1 <br /> AR <br /> -� <br /> 1 <br /> Q - <br /> I I I I I i+F1 F I 4P�_ I _T_ � I I I ' I _71 I I I I I I I I I I Al IAL_L_] <br /> T <br /> DE ARTMENT U E ONLY <br /> Application Accepted B w Date _ _ Area Employee ID#��i7iyr"_�ro <br /> Grout Inspection i �> Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date � L ❑ WAIVER Received <br /> Soil Boring Inspection By A/ Date <br /> {l���� ��/ Constructed Well Depth ft <br /> CCfoiP1GNTS .. 'SLS � L�L�C'v �J1ZG�+/t�-+, t2e' �, ------ - <br /> PE SC Received Chet Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B. Cash Remitted Service Request# <br /> 11h) , Q0 Ro0AAI Il <br /> tat <br /> Sr�100_7ZO <br /> C;043-06 WELL/PUMP PFRMiT <br /> 130.12 <br />