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LGA <br />R A <br />WELUPUMP PERMIT <br />} SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />Permit) Invoice # Well ID# <br />Service Re uest# <br />3`381 N. <br />Seh erAKb'. <br />ca r+ 9 5aa0 <br />Joe ADDRESS <br />50AIL`rL7 <br />CITY/ZIP <br />C <br />CROSS STREET pe <br />1-i I c r <br />APNIO a (I O � 7/ PARCEL SIZE <br />LAND USE APPLICATION # <br />OWNER NAME <br />PHONE <br />OWNER ADDRESS �v <br />�f'�f .,-77 <br />`� W <br />U /V �% • CITYISTATE/LP1 <br />��YvL <br />CONTRACTOR <br />e r <br />-4(/^+' C�^1 79� <br />%�PHHO�NEE <br />"� A, Q <br />CONTRACTOR ADDRESS <br />CITYISTATE/2]P <br />1 1 1 1 T•+�+� <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />EXPIRATION DATE �' ) <br />LICENSE C-57 <br />C-61 D-09 <br />Other NUMBER Ocy <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />WENDED USE Domestic/Private Irrigation/Agricultural _ Industrial _! Water Quality Monitoring i Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Wte, System Neme uontact Name or Phone Number <br />TYPE OF WORK "New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells ; Soil Borings) # of borings Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal ri Cross -Connection Repair <br />Drilling Method -AMud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth K 9Q/ ft ExcavationI� in diameter Open Bottom Gravel Pack/Gravel Size Ilii ~ in diameter <br />Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched G 940 Steel XPlastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) )(Sand Cement 10.3 sack mixf7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped i Free Fall Other Retardant /Accelerator (name) <br />PEDESTAL Installed ByxDriller Pump Contractor Other <br />oncrete destal Dimensions: Width 5 It Length It Thick G in Christy Box I 1 Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set Y1190 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 COMPENSATION LAWS. <br />MINIMW 24 HOUR ADVANCE NOTICE REQUIRED FO\R' INSPECTIONS - PLEASE CALL (209) 95? -7697 <br />SIGNED_ TITLE TITLE V t«Std�ri� DATE <br />Application Accepted <br />Grout Inspecti�n-E� <br />Pump Inspection By <br />Soil Boring Inspection B <br />COMMENTS V <br />N <br />, RTMENT VSE/ONLY <br />Date Area "l EmployeeID#-✓�"t�J <br />Date :1 SPECIAL Well Permit <br />1' Date ^ I WAIVER Received t( <br />Date _ Constructed Well Depth 0 j ft <br />PE SC Received <br />Codes Info B <br />Check#/ <br />Cash <br />Amount Date <br />Remitted <br />Permit) Invoice # Well ID# <br />Service Re uest# <br />cl -7-7 <br />aE;? uc; <br />50AIL`rL7 <br />C C- <br />EHD 43-06 v WELL/PUMP PERMIT <br />4/30/12 <br />