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•' - �• T� �, �� ' l is � l � `) .1-�;*, -1 -7, J�� � I� y �'�' ' J� <br />WELUPUMP PERMIT���I <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS <br />CROSS STREET n �� <br />OWNER NAME <br />OWNER ADDRESS v <br />CONTRACTOR C/9� <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />GALL (ZU9 <br />LICENSE 'r-6.57 rl C-61 'I D-09 11 Other <br />953-/bU1 FOR INSP <br />-"I Al DUr-M)1 <br />PAI <br />"; 1'e,1 <br />;GTI77OLLN5 pMAII-111I T tArt rNUIVI um l c wavvu <br />_64 <br />1 �lzlp <br />CEL SIZE LAND USE APPLICATION # <br />lie PHONE /- �i� 33 .- 03-2 <br />CITY/STATE/ZIPS�cod, q Vj/ Z% <br />PHONE n`-1�cS' �2� <br />CITY/STATE/ZIP X_,,,,, l.� / ^ " an <br />PHONE <br />tCITY/STATE/ZIP <br />NUMBER EXPIRATION DATE Z _ 31 17-- <br />GEOGRAPHICAL <br />7 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Rancie Section <br />NTENDED USE omestic/Private [ Irrigation/Agricultural U Industrial i7 Water Quality Monitoring ❑ Soil Sampling/Characterization <br />[1 Public Water System <br />If different from Owner: Water System Name —pct Name or Phone Number <br />TYPE OF WORK [* IVew Well N/Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) If of wells ❑ Soil Boring(s) # of borings Geotechnical a of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />[1 New Pump n Pump Replacement ❑ Pump Repair 11 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method 6-14ud Rotary ❑ Air Rotary Cl Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth yan It Excavation ! :Ly/ in diameter ❑ Open Bottom n Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter In Thickness/Gauge/ASTM Sched YOO 2 I '1 Steel Plastic C! Stainless Steel ❑ Other <br />Grout Seal Deptf D -_ft 1 Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />CI Bentonite (20% solids) '.1 Other <br />Grout Placement Method L�4umped _1 Free Fall 7, Other U Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br />Concrete Pedestal .-I Dimensions: Width It Length It Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP I -I Submersible[ 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 *D ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS OMPENSATION LAWS. <br />MINIMUM 24 �`O R DVANCE NOTICE REQUIRED FOR INSPECTIS EASE CALL (209) 953-7697 <br />SIGNED o �,� `I TITLE Ok'—wr S S DATE 3 — �2 y --y 7 <br />D PARTMENT U E QNLY <br />Application Accepted / Date / <br />Grout Inspection By �T�'a��.�, Dates <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS w,-evt__ fer-",AAe'S IAA C's r "VA, <br />Area '�'71V Employee ID411r <br />� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Const;"d Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />heck <br />ash <br />Amount <br />Remitted <br />Date <br />ermiV <br />Service Request # <br />Invoice # <br />Well ID# <br />�O gds <br />2 <br />31 1, <br />3ftf)-7 709 0 <br />W rbo3y,'os(9 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />T <br />m <br />D <br />v <br />v <br />m <br />m <br />N <br />