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WELUPUMP PERMIT <br /> SAN JOAouiN 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 /> S N IR -(-o -tyv, N <br /> JOB ADDRESS . L Ie L4 <br /> CIrv21P D <br /> CROSS STREET �'Npoil y"C'n C APPN 11+1 ��L�V-t� PARCEL SIZE I+LAND USE APPLICATION# 9 <br /> OWNER NAME [7�'/C./✓11a Inc 1 o 1'S o 1 �/J� ( PHONE 2ag. �N/4.. 13 7 � N <br /> OWNER ADDRESS � l�.71 op D&L-1'C� S 1 , CITY/STATEIZIP, G lcr,: ' ,(/H q ss I <br /> CONTRACTOR `,^ I-e, 0 +w. D t1 '.Wry���(�W •��-y-;/1�� /to <br /> CONTRACTOR ADDRESS I oo I S!"461, 73' CITY/STATE/ZIP �� I C4 Ja v <br /> SUBCONTRACTOR N I PHONE <br /> SUBCONTRACTOR ADDRESS CIITTTY{�/S/T(ATE21P <br /> LICENSE C-57 L C-61 U D-09 U Other NUMBER l"` pIRATION DATE V <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE XDomestic/Private 7 Irrigation/Agricultural O Industrial ]Water Quality Monitoring C Soil Sampling/Characterization <br /> U Public Water System <br /> If different from Owner. Water SYSteM NarrM Contact Name-o-r one um er <br /> TYPE OF WORK �Q New Well L Replacement Well U Well Alteration/Modification U Other <br /> /❑Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings 0 Geotechnical #of borings <br /> 0 Out-Of-Service Well 0 Out-0f-Service Well Renewal ❑Cross-Connection Repair <br /> U New Pump L Pump Replacement U Pump Repair U Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mud Rotary C Air Rotary C Auger 7 Cable Tool ❑Push Point 0 Other <br /> Proposed Well Depth ?pQ1D ft Excavation 1,4- in diameter U Open Bottom U Gravel PacklGravel Size in diameter <br /> n Conductpr Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched n Steel )(Plastic fl Stainless Steel ]Other <br /> Grout Seal Depth 2vU ft C Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack mW7 gal water <br /> P Bentonite(20%solids) L Other <br /> Grout Placement Method APumped ❑Free Fall C Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ]Driller C Pump Contractor 7 Other <br /> 0 Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box 0 Stove Pipe <br /> PUMP ❑Submersible]Turbine C Other HP Pump Set 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 C N ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT C IVE WITH CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKER C M ATION L <br /> IM 24 HO A QUIRED FO INSPECTIONS-PLEASE CALL(209)9 3-769 /� <br /> SI TITLE V�'1 1 Y & DATE ib-4 Y41, <br /> -44N <br /> 2,g <br /> ✓oq -2018 <br /> tT/ Fpq' ot/N�' <br /> RTMFHT <br /> EPARTMENT USE ONLY <br /> Application Accepted By Date Area 1 Employee ID# //,�1 <br /> Grout Inspection By Data ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring In echo ate Constructed�ell� Depth ft <br /> CO`M.MEN S � �i1'LT a PL/1l,Z� (�try7 <br /> C so <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# WeIIID# <br /> Codes Info B Remitted Service R uest# <br /> 43(-c 3 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4130/12 <br />