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IAI <br /> G0 =/r-'t WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS J�J V O� 44 1 �1�(1 CITY/ZIP�`- ��I':&2"4 �j % D <br /> CROSS STREET 6X1'1 C� APN tf2,QT=,Q 7AQ: ZR PARCEL SIZEI�LAND USE APPLICATION# m <br /> N <br /> �IjJ/ <br /> OWNER NAME rA Id Qi�" . ..- <br /> Im may- / <br /> l 7I PHONE %`9566 <br /> l <br /> OWNER ADDRESS 7 15�S/f�1 A E /M It14� CITY/STATE/ZIP <br /> CONTRACTOR Mff sL-a�!L h//�rg PHONE <br /> CONTRACTOR ADDRESS f l / / i/�S r2-j CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 7 <br /> LICENSE C-57 `7 C-61 1 D-09 C7 Other NUMBER n EXPIRATION DATE<©I <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring U Soil Sampling/Characterization <br /> Cl Public Water System <br /> If different from Owner: Water System Name ontactName or Phone Number <br /> TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #or borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> [; New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodXMud Rotary ❑ Air Rotary r, Auger Ll Cable Tool Cl Push Point 0 Other <br /> Proposed Well Depth e2 RO ft Excavation -/Z— _ in diameter 1 Open Bottom ravel Pack/Gravel Size in diameter <br /> U Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Z Of IJ Steel IfbflPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth/00 ft I1 Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ;1 Other <br /> Grout Placement Method><Pumped D Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller XPump Contractor U Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP [' Submersible[I Turbine I; 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 COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7�6�97 <br /> SIGNED�� C p✓lGlil,l��sr/ TITLE1J1/`L�• P� DATE <br /> L hZ <br /> 11 1 <br /> l <br /> A <br /> A J A <br /> N'v IRC NN EN TAj <br /> d E T <br /> DE ARTMENT USE ONLY <br /> c <br /> Application Accepted By Date_ Area4laA Employee ID#';y <br /> Grout Inspection y Date Sf ❑ PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructeu Well Depth ft <br /> COMMENTS w <br /> ` — b �iag- <br /> PE SC eived he]. Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> EHD <br /> 4/30112-06 � f �7_ G/7— ��_ �'j -7ZC f�CC� �j A/ LL/PUMP PERMIT <br />