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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT - 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />IVUIN-REFUNDABLE PERMIT t;ALL "LU9 853-7697 FOR INSPECTIqNS n EXPIRES 1 YEAR FROM DATE ISSUED <br />L4 a <br />JOB ADDRESS ��� CITY/ZIP'-"-'�G i /Z ///1 <br />CROSS STREET AP IPSO %0/0 /,4;6ARR� <br />CEL SIZE --La--LA.D USE, <br />OWNERNAME LG _(,4 -� A -w aae-4-ONE_ <br />OWNER ADDRESS D ttt b CITY/STATE21P, <br />ADDRESS <br />:TOR ADDRESS <br />j C57 L C-61 U D-09 U <br />PHONE <br />CIN/STATE/ZIP <br />CITY/STATE/ZIP <br />NUMBER EXPIRATION DATE <br />".VUKAFNIGALMFUHMAHUN: uooromacesa If TOWnShip_ Range Section <br />(TENDED USEDomestic/Private D Irrigation/Agricultural ❑ Industrial :1Water Quality Monitoring C Soil Sampling/Characterization <br />Public Water System <br />Ifdfferent from Owner.Water system Name Contact Name or Phone NUMber <br />TYPE OF WORK ^ New Well L Replacement Well U Well AlterationlModification U Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Bodng(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -0f -Service Well Renewal ❑ Cross -Connection Repair <br />ew Pum "L Pump Replacement U Pump Repair U Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary C Air Rotary C Auger 7 Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth it Excavation in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter <br />F1 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ft Steel r1 Plastic n Stainless Steel -1 Other <br />Grout Seal Depth ft C Neat Cement (94 1b bag/5-10 gal water) ❑ Sand Cement sack m1x/7 gal water <br />U Bentonite (20% solids) L Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall C Other ❑ Retardant/ Accelerator (name) <br />PEDESTAL Installed By 7 Driller C Pump Contractor A Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible? Turbine C Other HP Pump Set ft Standing Water Level -2-& _ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORR 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 />MITICE A VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE 114 1"76N- DATE <br />Application Accepted ty <br />Grout Inspection 1% <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />ARTMENT U E O LY <br />Date Area Employee ID# <br />_ <br />Date <br />�. ��� ❑ S CIAL ell Permit <br />Date ❑ WAIVER Received <br />Date Constructed Well Depth 2_Z—(h <br />eft <br />OPQVIPI G®U� � <br />EN�1RONPA� N+��.15 <br />nL�N DE <br />PE <br />Codes <br />Sc Received <br />Info B <br />Check#/ <br />Cash <br />Amount <br />Remitte <br />Date Permit/ Invoice# WellID# <br />Service Request # <br />1XV dv <br />k <br />Wroo3710 +0 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />