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1 <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEW 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />CALL Z09 953-7697 FOR INSPECTIONS 1 XPIKtb l YEAR FROM LIATE ISSUED <br />JOS ADDRESS <br />✓ 0 <br />, J ,. 'TY/ZIP <br />/ S,A� <br />CROSSSTREET <br />'�(- <br />APN ) <br />iJ ! tl PARCEL SIZE �! <br />D Use APPLICATIONr/# <br />OWNER NAPE <br />1 <br />7L 1 <br />j <br />OWNERADDRESSZ <br />v <br />/ :� C- <br />C <br />tZ <br />CONTRACTOR <br />�� <br />I(I� (T <br />`STATEIZIP <br />IandI - <br />�7n <br />i _�/�✓l <br />HDN <br />CONTRACTOR ADDRESS <br />, _� <br />` l <br />CRYISTATFJiJP <br />/ <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CfTY/STATE/LP <br />LICENSE <br />ii G-61 D-09 fl Other <br />NUMBER -� �� <br />•' <br />E7(PIRATIDN DATE <br />GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range Section <br />miyoED UsE 0 Domestic/Privale IrrigetiordAgricultural 0 Industrial ❑ Water Quality Monitoring ] Soil SamplingrCharadedzation <br />U Public Water System <br />udllferenttmm Owner: vVeferEwm Name CbMaCt NaMOof P110M NUff1ber <br />TYPE OF WORK O New WeII 3 Replacement Well C Well Alteration/Modification u' Other_ <br />r Monitoring Well(s) # of wells roil Boring(s) 9 of borings i t Geotechnical D of boil gs <br />LI Out -Of -Service Well C Out -Of -Service Well Renewal i t Cross -Connection Repair <br />'It New Pumo -� PUmD Replacement C Pumo Reoair 0 Raise Well Casino <br />Drilling Method D Mud Rotary Air Rotary C Auger 7 Cable Tool O Push Point r Other <br />Proposed Well Depth It Excavation in diameter 7 Open Bottom _l Gravel PacklGravel Size in diameter <br />C Conductor Casing in diameter I Conductor Casing Depth It <br />Well Casing Diameter` in ThitlmessrGauge[ASTM Sched Steel i i Plastic rI Stainless Steel r, Other <br />Grout Seal Depth it iT Neal Cement (94 Ib bag/5-10 gal water) q Sand Cement sack mod7 gal water <br />0 Sentonite(20%solids) D Other <br />Grout Placement Method O Pumped 3 Free Fag C Other ' Retardant I Accelerator (name) <br />PEDESTALtalled By il. Dn71er i Pump Contractor n Other <br />Ins <br />I Concrete Pedestal nDlmonsions: Width H Length R Thidt in 'I Christy Box -1 Stove Pipe <br />PUMP uhmelsibleCl Turbine D Other HP Pump Set R Blanding Water Level R <br />I HEREBY CER FY 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 COMPENS�APOwi:�Ws. <br />MINI U UR ADVANCE NOTICE REQUIRED 179"SPECTIONS - PLEASE CALL (209) 953-7697 <br />$IGRED- , TME -'.G..+..�� - DATE <br />�i <br />G4 <br />m <br />a <br />EP TMENT U E O LY (�j� <br />Applira6on Accepted B Dalo=z Area <br />` Employee IDR <br />Grout Inspection By Data ❑ SPECIAL Well Permit <br />Pump Inspection By �' Date �- ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth it <br />COMMENTS <br />PE SC Received Check#/ <br />Codes Info B Cash <br />Amount Date <br />Remitted <br />P. -I Invoice# <br />Service R uest# <br />Well ID# <br />Et1WELL?UMP PERMIT <br />41:301120112 (�� � r010J <br />