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)k_WELUPUMP <br />PERMIT <br />S.cr✓ .ih SAUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON41EFUNDABLE PERMITCALL 209 953-7697 FOR INSPECTIONS -_ hXl'IHt 11 TEA FROM LJAIt tlbbUUtu <br />JOB ADDRcSS tg�I ��i -� CITY/ZIP r,5 ` TA 77A <br />CROSS STREET �A( PN�/� 2-50— 0(0Q-0'1 PARCEL SIZE O 5kAND USE <br />�AP�P'.LIICj{ATION ## �t� <br />OWNER NAME I�iy/r/` �� / " /TL -i— PHONE c! ai(�" - ✓7 O — Y'YZ- <br />OWNER ADDRESS <br />CONTRACTOR 101eemy"' EU S - PHONE ;7j7l� <br />7 A O R <br />' <br />CONTRACTOR ADDRESS Ly��'/lze `��I—� CITY/STATE/ZIP L <br />SUBCONTRACTOR �T4�' (1�.�CfiQ a/` ISI PHONE <br />SUBCONTRACTOR ADDRESS // /6 'JIN I �CITY/STATE/ZIP Vf;:�;27 <br />LICENSE k;t-57 -61 i l D-09 P Other NUMBER EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE 4"nomestic/Private C7 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Ci Soil Sampling/Characterization <br />[1 Public Water System <br />If different from Owner: Water System Name ontact ame or Phone umber <br />TYPE OF WORK >INew Well [ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings v Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal U Cross -Connection Repair <br />IlNew Pump Fl Pump Replacement ❑ Pump Repair r7 Raise Well Casinq <br />WELL CONSTRUCTION <br />Drilling Method U Mud Rotary U Air Rotary [, Auger U Cable Tool U Push Point U Other <br />Proposed Well Depth_ eO It Excavation . Z in diameter U Open Bottom AlGravel Pack/Gravel Size _ in diameter' <br />U ConductoJ `sing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ In Thickness/Gauge/ASTM Sched 44 '_1 Steel ►Plastic C Stainless Steel ❑ Other <br />Grout Seal Depth s`b- <br />--J Neat Cement (94 Ib bag15-10 gal water) and Cement^'Zo' sack mi�7 gal water <br />1 Bentonite (20% solids) � I Other _ <br />Grout Placement Method)%Pumped _) Free Fall 11 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller Pump Contractor Other <br />Concrete Pedestal mensions: Widthft Length ft Thick in Christy Box FI Stove Pipe <br />PUMP Submersible r; Turbine 11 Other HP _ I 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 COMPENSATION LAWS. <br />MINNN� 2$ HA/NNCCEE NOTICE REQUIRED FOR/IINN$PPE,CTIONNS - PLEASE CALL (209) 953-769 <br />SIGNED /ice Lr`�"//b� �_ TITLE d�s� V i(J `� DATE <br />nFPARTMENT LISE ONLY <br />Application Accepted By We l Z <br />Grout InspectionAli Date <br />Pump Inspection By ONA—jDate -Al, <br />Soil Boring Inpection By <br />Date <br />T <br />m <br />D <br />v <br />O <br />m <br />m <br />N <br />c- <br />^ C• n <br />Area_. / t tmpluyee ii)#� , <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE <br />SC <br />Received <br />Check#/ <br />Amount <br />Date <br />Permitl <br />- U <br />Invoice # <br />FJ <br />Well ID# <br />Codes <br />Info <br />By <br />Cash <br />Remitted <br />Service Request # <br />3W -vv <br />-7,,Z5 <br />75'f <br />WW SPD I <br />"90 <br />i Oso <br />143 3 <br />s3 • vt) <br />of <br />59-M7 53 <br />00 w <br />�-- <br />_ i <br />EHD 43.06 WELL/PUMP PERMIT <br />4/30/12 <br />