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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)466-3420 <br /> NON-REFUNDABLE PERMIT ,,CC/ALL 209)9�J533-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> in <br /> JOB ADDRESS �y1 (,/.���( � `"� CITY/ZIP / y <br /> v <br /> CROSS STREET,*&rkrOAd APN PARCEL SIZE Qy_LAND USE APPLICATION# m <br /> OWNER NAME ✓ . ' PHONE //0,/ /D/ / `6 <br /> 21 Z <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> / <br /> CONTRACTOR /l 3 u///!6 /riYi PHONE AM777 •-77x7 <br /> CONTRACTOR ADDRESS&2, V ���1�, /G/ CITY/STATE/ZIP rlAt9,f c0i4 ✓iF5 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 n D-09 ❑ Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE Domestic/Private 11 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 11 Public Water System <br /> If different from Owner: Water System amemac_ ame or Phone Number <br /> TYPE OF WORK ❑ New Well }Q Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) It of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical a of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump C Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUC1je0N <br /> Drilling Method )(Mud Rotary <br /> ❑ Air Rotary ❑ Auger qr ❑ Cable Tool [J Push Point ❑ Other <br /> Proposed Well ot <br /> Depth Excavation �y� In diameter ❑ Open Bottom ,`Gravel Pack/Gravel Size 7& _In diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter, ! in Thickness/Gauge/ASTM Schedjo Z/ [] Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth " it [l Neat Cement(94 1b bag/5.10 gal water) f0anclCement oea•:5 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method W Pumped J Free Fall n Other [? Retardant/Accelerator(name) <br /> PEDESTAL Installed By �(Driller ri Pump Contractor ❑ Other <br /> Concrete Pedestal['Dimensions:Width LV.1:5it Length ft Thick in ❑ Christy Box n Stove Pipe <br /> uMP4 Submersible[) Turbine ❑ Other HP Pump Set it Standing Water Level ,z, 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 COMPE SATION LAWS. <br /> M;M M HOU VAN NOTICE REQUIRED FO ECTIONS-Pj.EASE 9ALL(209) 953-7697 ` <br /> SIGNED TITLE �L+� ATE -I 7-16e <br /> P <br /> V All Fi 11 <br /> Orr iii <br /> t <br /> ENV H( AA <br /> fF U.P H enrN <br /> Q PARTMENT US ONLY <br /> Application Accepts Date 11 Area L Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Dateqy�x� Constructed Well Depth h <br /> COMMENTS � VVEGC. MEIII 14�✓✓��E�� pL CAA4T <br /> PE SC Received Check#/ Amount Date PermfU Invoice# Well ID# <br /> Codes Into B Cash Remitted Service Request# <br /> 8� Let �" o97�TI �D ,i III, 5KCb_)Ival <br /> t a <br /> EMD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />