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WELUPUMP PE P J <br />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 <br />CROSS STREET <br />3-7- i SiaZ1,14Z 1�2e/ CITY/ZIP <br />'ee/APN PARCEL SIZE LAND USE APPLICATION # <br />DWNER NAME i 71 J .! --J'iIrl < <br />DWNER ADDRESS 3 77/ Sa" IW /� akLl <br />CONTRACTOR t—V� <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE /KC -57 C-61 i D-09 1 i Other <br />IV 10/ Ll-'-E1JCPHONE / <br />CITY/STATE/ZIP / �y C K-' <br />PHONE --2 7;72 -275-7 <br />CITY/STATE/ZIP 0 ), s <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 2 12. EXPIRATION <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE Y Domestic/Private i Irrigation/Agricultural Industrial -1 Water Quality Monitoring i ' Soil Sampling/Characterization <br />I Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK i New Well 1 i Replacement Well i Well Alteration/Modification 1 Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings i Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal i Cross -Connection Repair <br /># of borings <br />_'p4AWa6R mP A Pump Replacement Pump Repair i Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool I Push Point 1 Other <br />Proposed Well Depth ft Excavation in diameter . Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched i Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft i Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set /�( ft Standing Water Level /2 0 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 I 24 HOUR/� NC NOTICE REQUIRED FOR INSPE TIONS - PL ASE CALL (209) 953 76-977 <br />SIGNED G ` TITLE Ll n 4-:�C %� ✓I DATE <br />DEPARTMENT USE ONLY <br />Application Accepted \ Date <br />Grout Inspection By e/ Date <br />Pump Inspection By "�/ l'` <br />kAl "'%� Date 1017, 0 (% <br />Soil Boring Inspection By Date <br />COMMENTS <br />T <br />m <br />D <br />O <br />O <br />m <br />m <br />i <br />Area % Employee ID# <br />❑ 4PECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />IV <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br /><Che <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />IS- <br />S- <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />