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1t � <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVVN-KEFUNOABLE�JrLKMIT <br />t ALL kZUVj1 `J03-/dy/ FOR INSPECTIONS <br />t:JkFl Ktt_b I YEAR FROM UATEE ISSUED <br />Invoice# WeII1D# <br />41'52-OI <br />JOB ADDRESS <br />CITY/LP <br />V^►`°�y • t S 2 -OI <br />`�) <br />)tk 1az& <br />0& d GLAND <br />CROSS STREET VCJ\ <br />APN PARCEL SV -E <br />USE APPLICAQTI\ON # <br />OWNER NAME <br />n2�- <br />1 (y^ (,� <br />PHONE ),3/�\S(",ZS i�{/l <br />OWNER ADDRESS <br />CITYISTATEIZIP- <br />,�C�np;�p <br />�� }1�-�\tr\ '3 <br />CONTRACTOR � t \�W(.(7��r <br />C ^,.� <br />P -Ca? JIJMV� <br />2k <br />PHONE (2QE� C\D'Q'cm .} % <br />CONTRACTOR ADDRESS IkbILD 0 , <br />(^dr i CITY/STATEIZIP <br />� k" }y` I C8 ' `5LC-IS <br />SUBCONTRACTORN' <br />`T� <br />PHONE <br />-N' <br />SUBCONTRACTOR ADDRESS ` _ <br />Y CITY/STATE/ZIP <br />14 ho,,q <br />LICENSE f�57 -9.5111'�� D-09 <br />: Other NUMBER Zb I <br />` 1 <br />EX%RATIONDATE o `(\'T <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE DomesticIPrivate L Irrigation/Agricultural 1 1 Industrial C Water Quality Monitoring -1. Soil Sampling/Characterization <br />i Public Water System <br />If different from Owner: Water System Name CordaCtNameorphone u r <br />TYPE OF WORK ❑ New Well 7 Replacement Well r_ Well Alteration/ModificationI_l Other <br />1 Monitoring Well(s) # of wells i Soil Boring(s) n of borings 11 Geotechnical 9 of borings <br />I_' Out -Of -Service Well r <br />ll [ Out -Of -Service Well Renewal i Cross -Connection Repair <br />L. New Pump /I. Rump Replacement i Pump Reoair ! i Raise Well Casino <br />Drilling Method ; Mud Rotary i Air Rotary C Auger ; Cable Tool iJ Push Point I Other <br />Proposed Well Depth It Excavation in diameter J Open Bottom I Gravel PaddGravel Size in diameter <br />J Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Schad J Steel II Plastic n Stainless Steel I I Other <br />Grout Seal Depth ft I I Neat Cement (94 lb bag/5-10 gal water) i I Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) 1,1 Other <br />Grout Placement Method Ei Pumped 7 Free Fall J Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller 1 Pump Contractor Other <br />Concrete Pedestal r Dimensions: Width ft Length ft Thick in 1 Christy Box _, Stove Pipe <br />PUMP Submersible i.; Turbine ❑ Other HP Pump Set t4OO ft 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 />MI MUM R DV E NOT UIRED FORINSPECTIO)N�S(- LEASE CALL (209) 953-71697 <br />"t;/IIyJ�!� <br />SIGNED .4 -nnty DATE <br />eP <br />�1 <br />V <br />RFcE QED <br />�19 <br />5R282017 <br />SAN J'aA <br />E yy/R QUIN CO <br />EAl.?N. EPAR4'q I <br />rMEti? <br />26 <br />vl ' r Ai.. 1-IS_-LL11H <br />DEPARTMENT YS�7EjjONNLY <br />Application Accepted B Dateap/i Area Employee ID#�O <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />PE SC Received <br />Codes Info B <br />Cash <br />Amount Date Permit/ <br />Remitted Service R uest# <br />Invoice# WeII1D# <br />;.7061 <br />+7o, d c <br />Wf00 upL <br />EHD 43-06 WELL /PUMP PERMIT <br />4730tI2 <br />