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WELUPUMP PERMIT <br /> SAP.IOAOUIN 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 /> J r � y � <br /> JOB ADDRESS / 4 `5/ °� / f ''l V`4�` CITY/ZIP 7 — m <br /> D <br /> y t o <br /> CROSS STREET Le , /{`- 14/ ��s /U APN ��U�� f c} ? PARCEL SIZE ' ,(.QLAND USE APPLICATION# m <br /> � 32.:(3N <br /> OWNER NAME � ' �L _ PHONE <br /> OWNER ADDRESS _ fr, �� , CITY/STATE/ZIF •C l . <br /> s 7 <br /> CONTRACTOR ��he"if ",{/� '• // -7 7' �1 n _ _ PHONE�/l am6, 2 Ls <br /> CONTRACTOR ADDRESS `3L� J• , ` i l3 +� CITY/STATE/ZIP! e-���� �C { G� <br /> SUBCONTRACTOR _ —_, PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP J <br /> LICENSE L C-57 'I C-61 f) D-09 P Other NUMBER Y3—y'"-'EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br /> INTENDED USE4--Domestic/Private C: Irrigation/Agricultural 11 Industrial Water Quality Monitoring L Soil Sampling/Characterization <br /> I I Public Water System <br /> If different from Owner: Water System ame contact Name or Phone Number <br /> TYPE OF WORK t1lew Well 111 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) _ #of wells ❑ Soil Boring(s) If of borings L Geotechnical #of borings <br /> ❑ Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> [I New Pump Pump Replacement ❑ Pump Repair 11 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method "ud Rotary ❑ Air Rotary Auger G Cable Tool U Push Point ❑ Other <br /> Proposed Well DepthV_i ,ft Excavation - (/ - in diameter 7 Open Bottom ❑ Gravel Pack/Gravel Size!!15 in diameter <br /> LI Conductor Casing in diameter / Conductor Casing Depthft <br /> �� <br /> Well Casing Diameter� in Thickness/Gauge/ASTM Sched d R2 1 _1 Steel L(-Piastic C Stainless Steel ❑ Other <br /> Grout Seal Depth-&'4� ft Neat Cement(94 lb bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> 4'Btnlo ite(20%solids) I i Other <br /> Grout Placement Method+73-'dumped I Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By LI Driller ;00 t p Contractor CI Other <br /> Concrete Pedestal i- Dimensions:Width ft Length ft Thick in L Christy Box 1-1 Stove Pipe <br /> PUMP c--<ubmersiblel; Turbine 11 Other HP Pump Set It 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 ATIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP <br /> SATION LAWS. <br /> MINI M 24 nUR A VA, CE NOTICE REQUIRED FOR INSPECTION P ASE CALL (209) 953-7697 <br /> 6 <br /> SIGNED '9!� �., TITLE 1- ,rn, DATE _ <br /> v <br /> J � a <br /> 4 ^- <br /> D� PA RTM E NT U S O N L Y <br /> Application Accepted B�­.— Date �I_- —_� --- Area Employee ID <br /> �( <br /> Grout Inspection By ��'= > Date f' ❑ SPECIAL Well Permit <br /> Pump Inspection K Date ❑ WAIVER Received <br /> Soil Boring Inspection By _ Date Constructed Well Depth ft <br /> CO EN TS I�Y18—[X-9 IAI <br /> 01 <br /> PE SC Rece ved -Check##// Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> '?0,12 WELL/PUMP PERMIT <br />