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WECVPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1869 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / i' ITY21 P �/ > <br /> C m <br /> yy 7� _ o <br /> CROSS <br /> 'TREE (Y ✓�' APN l�I 0 PARCEL SIZE AND USE APPLICATION# m <br /> OWNER NAME � �s °`LS _- PHONE f;l 2 , �n <br /> OWNER ADDRESS CITY/STATE0P <br /> CONTRACTOR 9 xs !Ll,(N PHONE .] �/a 41 f <br /> CONTRACTOR ADDRESS !''{J •" CITY/STATE/ZIP ���!/(� r4I /L <br /> SUBCONTRACTOR PHONE r1 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE i�<C-57 I C-61 D-09 Other NUMBE f EXPIRATION DATE C <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE I Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name ontack Rame or Phone Number <br /> TYPE OFWORK--w!�New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal I Cross-Connection Repair <br /> ew Pump i Pump Replacement Pump Repair I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method <br /> Nud Rotary !-I Air Rotary Auger Cable Tool I Push Point Other <br /> Proposed Well Depth300 Excavation (r In diameter I Open Bottom >e_Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter' / Conductor Casing Depth ft <br /> Well Casing Diameter_t? in Thickness/Gauge/ASTM Sched 7-,32Steel ;%glastic Stainless Steel Other <br /> Grout Seal Depth _'�;O ft Neat Cement(94 lb bag/5-10 gal water) sand Cement X2 sack mW7 gal water' <br /> Bentonite(20%solids) Other <br /> Grout Placement Method keumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ADriller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width C _ft Length it Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP 0 Pump Set ft Standing Water Level it <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 /> MIN 24 HQUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209)959--7697 <br /> SIGNED ��' TITLEP>�!S�+d+- DATE <br /> - l � <br /> L <br /> eX� G- <br /> C <br /> E PR T M E N T U E O L Y - <br /> Application Accepted By , Date Area Employee ID# <br /> Grout Inspection By Date I_l�SPECIAL Well Permit <br /> Pump Inspection By Date I I WAIVER Received <br /> Soil Boring Inspection By T Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit) <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> WO 49K-0a3 X14616 i0ld -Iyl� <br /> EHD 43-Ce WELL/PUMP PERMIT <br /> VIN12 <br />