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4, WELUPUMP PERMIT <br /> FiAN JOAO;;IN COUNTY ENVIRONMENTAL HEALTF!DEPARTMENT 1863 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> N9V-+EFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> i <br /> n I T <br /> iJoB ADDRESS 1 _l l/ _ CITY/ZIP / _ r" <br /> --- a <br /> A v <br /> CROSS STREET_ C!v�s✓�'�v01 APN OZ +1 S_PARCEL SIZE.4AND USE APPLICATION# <br /> n <br /> OWNER NAME �� (✓�.Lls PHONE <br /> OWNER ADDRESS _ /s1�]r � CITY/STATE21P g / �J�-7 _ <br /> CONTRACTOR � d1�'A �`j�/'/� / PHONE —., T ` —r <br /> CONTRACTOR ADDRESS _['�(f „�w7'� L �w CITY/STATE/ZIP_LC!/�r S!G �L l T-V <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE yCC 57 C-61 D-09 OtherNUMBEF�� EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X_ Y Township Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System _ <br /> If different from Owner: Water ystem ame Contact Name or Phone Number <br /> er <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal ' Cross-Connection Repair <br /> ew Pum Pum Replacement Pum Repair Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Metho�ud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 300 ft Excavation -� - In diameter Open Bottom ravel Pack/Gravel Size in diameter <br /> Conductor Casing -in diameter• / Conductor Casing Depth ft <br /> Well Casing Diameter-C?-- in Thickness/Gauge/ASTM Sched j� Steel 1I Blastic Stainless Steel Other <br /> Grout Seal Depth !i-Q- ft Neat Cement(94 lb bag/5-10 gal water) and Cement A-2, 7 sack mixl7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method dumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 4<Driller Pump Contractor I Other 1 <br /> Concrete Pedestal Dimensions:Width�ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP D 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 /> M 44 HQUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953--7697/ <br /> SIGNED ��' TITLE (7{ DATE ? ! <br /> l � <br /> Z <br /> it <br /> c <br /> 0 <br /> a = , <br /> 51I <br /> E6 RTMENT U E O LY - <br /> Appl?cation Accepted B Date ;?140/016 Area Employee ID# �� <br /> Grout Inspection •./' Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date I I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Arnount Date PermiU Invoice# Well ID# <br /> CodesInfo B Cash Remitted Service Request# <br /> I do <br /> --1,o3 " <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />