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• n1hal Smo to I� / ► ! /� `� ✓ <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN 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 ^ S f � CICITY/Zip�I�P�_[� .'e'- <br /> y PARCEL SIZECCROSS STREETb ✓0" Al APN LAND USE A <br /> PPLICATION# <br /> IOWNER NAME PHONE .7 <br /> OWNER ADDRESS <br /> -> / lI CITY/STATE21P.1 411 <br /> CONTRACTOR ev2 / -9 tIJI � PHONE <br /> E <br /> T� <br /> CONTRACTOR ADDRESS ---.- --- <br /> ,�[�} J, /�- t� Y CITY/STATE/ZIP. c-1 <br /> SUBCONTRACTOR ___—_ — PHONE <br /> SUBCONTRACTOR ADDRESS _ CITY/STATE/ZIP---- <br /> LICENSE L}t`-57 1 C-61 D-09 Cl Other NUMBER y��_J_- EXPIRATIONDATE J 3/ - /Z- <br /> -F <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y_ Township Range,_.__- Section <br /> INTENDED USE omestic/Private C. Irrlgation/AgrlCUltural I 1 Industrial .i Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 1 Public Water Systemm�e <br /> If different from Owner: Water System amFT e contact?fie oil o e-Aur _._ <br /> TYPE OF WORK [NVew Well I Replacement Well C Well Alteration/Modification rl Other <br /> G Monitoring Well(s) _ #of wells ❑ Soil Boring(s) _ n of borings Geotechnical If of borings <br /> C Out-Of-Service Well U Out-Of-Service Well Renewal 11 Cross-Connection Repair <br /> !1 New Pump Pump Replacement D Pump Repair 17 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ILr•-Mud Rotary I i Air Rotary u Auger I_; Cable Tool Push Point I- Other <br /> Proposed Well Depth V C7l:" ft Excavation I/ in diameter C Open Bottom Gravel Pack/Gravel Size ? in diameter <br /> I 1 Conductor Casing in diameter / Conductor Casing Depth <br /> Well Casing Diameter-Z-, in Thlckness/Gauge/ASTM Sched jQ/Z 2 1 U Steel ! tic I' Stainless Steel C Other__ <br /> Grout Seal Depth� It i Neat Cement(94 lb bag/5-10 gal water) C Sand Cement _ _sack mix/7 gal water <br /> 4-BtrftT n to(20%solids) 'i Other <br /> Grout Placement Method dumped -1 Free Fall r, Other L) Retardant/Accelerator(name) <br /> PEDESTAL Installed By !i Driller ►-Parnp Contractor _i Other <br /> Concrete Pedestal Dimensions:Width it Length It Thick in Christy Box I, Stove Pipe <br /> PUMP 6­5ubmersiblel: Turbine 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 ANDA TIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP SATION LAWS. <br /> MINNOM 24 UVA CE NOTICE REQUIRED FOR INSPECTIO PLEASE CALL (209)953-7697 <br /> w <br /> SIGNED "� w _ TITLE- �;�� ��' DATE, - <br /> 0.•i, �. <br /> D� P A R T M ENT US ONLY <br /> Application Accepted B, Date ��-- Areae-- Employee ID90F& <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By --_ Date Constructed Well Depth tt <br /> COMMENTS �) LSIGLb M,/f51Lt-. Vr;iW _(Al } _- <br /> PE Sc Received eck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Inco B Remitted Service Re uest# <br /> s <br /> Lk "ot <br />