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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 /> /� <br /> I o <br /> JOB ADDRESS -S ©DO R S+ irA Rj CITY/ZIP I-ret CV 1530 / R <br /> �, ,r� C <br /> CROSS STREET 1 APN Z' - I 10 —/iT PARCEL SIZ4,11-91-AND USE APPLICATION# rt <br /> OWNER NAME cc, N diva r r a PHONE <br /> OWNER ADDRESS 2Sa OO Nly-'J Q,4 CITY/STATE/ZIP BIC k <br /> CONTRACTOR MeL S e I I t I GC�Ip_r t I 't IAC I .�` PHONE S z— q?—a-- V <br /> CONTRACTOR ADDRESS I `�- 7'r I.be IS CITY/STATE/ZIP n4,9 01 � b. L fit %D7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS /'CIITY/STT/ATE/ZIP <br /> LICENSE �( C-57 fl C-61 f7 D-09 11Other NUMBER626 GG. EXPIRATION DATE / 36x-17 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section_ <br /> INTENDED USE ">K Domestic/Private n Irrigation/Agricultural ❑ Industrial n Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> Cl Public Water System <br /> If different from Owner: Water System Name Contact Name or enonG NurnDer <br /> TYPE OF WORK'$New Well [I Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> F1 New Pump ❑ Pump Replacement ❑ Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)fd'Mud Rotary ❑ Air Rotary ❑ Auger�f❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth GCS It Excavation in diameter 3 Open Bottom )(Gravel PacWGravel Siz —�12—in diameter <br /> ❑ Conduc Casing in diameter / Conductor Casing Depth it <br /> Well Casing D ` 0 <br /> iameter g in Thickness/Gauge/ASTM Schad� ❑ Steel ;K'Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft n Neat Cement(94 lb bag15-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> �Bentonite(20%solids) UOther <br /> Grout Placement Method umpad ❑ Free Fall ❑ Other C7 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br /> n Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box n Stove Pipe <br /> PUMP ❑ Submersible C; Turbine 1i 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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI�IIM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 / <br /> SIGNED ��,T)— �-- TITLE v DATE <br /> { <br /> t <br /> S <br /> y <br /> -441 <br /> 4 <br /> i <br /> DQ4PARTMENT SE ONLY <br /> Application Accepted B Date I Area Employee ID#( D �) <br /> Grout Inspection ,,, KDate / 0 SaeclaL WeII Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection y Date Constructed Well Depth ft <br /> COMMENTS <br /> C4u,5;-sys G r, - </ -7s 2 /J Y <br /> PE SC Received heck Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> `W tl1 <br /> *14&! 11t-k <br /> - r <br /> EHD 43-06 I WELL/PUMP PERMIT <br />