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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 /> N <br /> q ,t r <br /> Joe ADDRESS //O ,51.51/1 f14414 /J�r Ste��17f[ CITYrzIP��� <br /> CROSS STREET/JY6�K M�,4-0I`AfO a/✓�APIN_ 2,1 D �-5PARCEL SQE�LAND USEAPPLICATION# <br /> OWNER NAME C[?(/ //L'71B/�`J - ,(/ r� n'PHONE TIo , <br /> OWNER ADDRESS _ C- �( `l�� " 4V� �A CITY/STATErzIP_JJ+e+ttA4KT.A, <br /> CONTRACTOR ,/ If A -0 PHONE L76 <br /> CONTRACTOR ADDRESS ? S' ^/,r /lf. <br /> CITY/STATE/ZIP .Ql<71 CA 'S.3,-6 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATEIZIP ` <br /> LICENSE "-57 Il C-61 i1 D-09 11Othef NUMBER el,?'I.2 L EXPIRATION DATE S-3i'i <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section_ <br /> INTENDED USE omestic/Private , rrigatlon/Agricultural ❑ Industrial D Water Quality Monitoring 1i Soil Sampling/Characterization <br /> Cl Public Water System <br /> If different from Owner. Water System amenta ame or r, u r <br /> TYPE OF WORK 4YF1ew Well 11 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Wefl(s) #of Wells ❑ Soil Boring(s) #of botings ❑ Geotechnical 0o borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method r-95d Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool U Push Point ❑ Other <br /> 't1 <br /> Proposed Well Depth 3 O� it Excavation in diameter ❑ Open Bottom t9'C`,ravel PacWGravel Size � in diameter <br /> u Conductor Casing in diameter / Conductor Casing Depth tt <br /> Well Casing Diameter-e'in Thickness/Gauge/ASTM Schad -Who 'A l ❑ Steel @'Plastic D Stainless Steel ❑ Other <br /> Grout Seal Depth_1()0t+ it Cl Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mhd7 gal water <br /> ti,,56ntonite(20%solids) JOther <br /> Grout Placement Method 0115umped ❑ Free Fall n Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller _; Pump Contractor Other <br /> 1. Concrete Pedestal i-,Dimensions:Width_it Length it Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP C Submersible❑ Turbine c Other HP Pump Set it Standing Water Level ri <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 ANIDACTIVE <br /> WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C MPENSATION LAWS. <br /> MI IMU UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-P <br /> PP�ASE CALL(209)953-7697 <br /> SIGNED TITLE K3 fS DATE <br /> S N <br /> Vr C <br /> � T <br /> 0 <br /> 0 <br /> ro <br /> 1 <br /> 2 1 r R <br /> ¢ a'S <br /> D PARTMENT USE ONLY <br /> Application Accepted Date 0 b 12.016 Area "L'{ Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit •. 1 <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS <br /> (u1 144M �VAeLv'a5' 'e <br /> PE Sc Received ec Amount Date Permit/ Invoice# Well IDM <br /> Codes Info ash Remitted Service Re Request# <br /> I.°° )o I w SQ 0�71vo0 <br /> 'r3 u l� <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4x"12 <br />