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11 <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT c CALL (22009 9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS % S �5`/C_ �6/n �l� E Ake_ <br />63 <br />? / CITYTZIP l4 /1 rG/4 9 36 <br />CROSS STREET d-- / �O 4 (/1 Jfli i�� APN .2 D C1 J70 1 f� PARCEL <br />SIIZE./ 1 7 LAND USE APPLICATION If <br />OWNER NAMEHONNE, �7 <br />J1A( '*,.lir 11 „ <br />OWNER ADDRE! <br />CONTRACTOR <br />CONTRACTOR A <br />SUBCONTRACTOR <br />PHONE <br />t�,�oo�� c4. 933 8� <br />PHONE <br />SUBCONTRACTOR ADDRESS 'T'-1'1;2 <br />ITY/STATTE/ZIP® <br />LICENSE ;/C-57 t7 C-61 i1 D-09 [1 Other NUMBER T3ysc/Q EXPIRATION DATE 5' � 7 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE t< Domestic/Private ri Irrigation/Agricultural ❑ Industrial i Water Quality Monitoring U Soil Sampling/Characterization <br />[7 Public Water System <br />If different from Owner: ater System ame—contact ame or Phone Number <br />HYPE OF WORK P"N' ew Well 11 Replacement Well ❑ Well Alteration/Modification 0 Other <br />0 Monitoring Well(s) If of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />0 Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />[! New Pump r' Pump Replacement ❑ Pump Repair ❑ Raise Well Casina <br />It of borings <br />Drilling Method V Mud Rotary [ 1 Air Rotary ❑ Auger U Cable Tool L] Push Point ❑ Other <br />Proposed Well Depth 2 90 ft Excavation 11 in diameter ❑ Open Bottom gavel Pack/Gravel Size in diameter <br />Ll Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diame in Thickne s/Gauge/ASTM Sched R I t iJ Steel Y/ Plastic L', Stainless Steel ❑ Other <br />Grout Seal Dep �ft [1 Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br />entonite ° olids) ❑ Other <br />Grout Place ent Meth_ Pumped 7 Free Fall 77 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By U Driller Pump Contractor Other <br />Concrete Pedestal i- Dimensions: Width ft Length It Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP submersible❑ Turbine r; Other HP Pump Set ft Standing Water Level 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 OMPENSATION LAWS, <br />M IMUM H UR ADVANCE NOTICE REQUIRED FOR INSPEC7SI53 <br />NS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE C Il P� DATE 12 —') 7 p . /6 <br />DkPARTMENT,USE/ ONLY <br />Application Accepted By c D <br />Grout Inspectione <br />Pump Inspection By Date <br />Soil Boring Inspection B/y-- 9 Date <br />dMENTS r�1W1, � �� /v hf/_49-0-AW-F, <br />_ AW , <br />SAN'3V <br />EN <br />AreaA IF I <br />Emplp <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />Iii <br />T <br />m <br />D <br />0 <br />0 <br />M <br />M <br />N <br />N <br />PE <br />Codes <br />I SC <br />Info <br />Received <br />By <br />heck#/ A1rount <br />Remitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Well ID# <br />on <br />10 <br />J6 <br />4/30/12 <br />WELL /PUMP PERMIT <br />