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WELUPUMP PERMIT P'--- <br />SHN JOAQUIP COUNTANVIRONMENTAL HEALTH DEPARTMENT 1 £68 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT <br />Grout Inspection By <br />UALL <br />1t/ Ub:i-!b9[ FOR INSPECTIONS txijlHt5 l YEAR FROM DATE SSUED <br />Date Z <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />JOB ADDRESS <br />3/7z> <br />CITY/ZIP <br />CROSS STREET <br />( VVI= <br />APN <br />! — . PARCEL SIZE ZU LAND USE APPLICATION # <br />OWNER NAME <br />c <br />rte, b Mand IA r <br />�PHOON <br />)F� <br />yy\ 14�, <br />GI C C <br />OWNER ADDRESS <br />CITY/STATE/ZIP � <br />'Q3 <br />CuNTRACTOR <br />t' <br />_ <br />PHONE <br />G <br />/ <br />c C C4 <br />�C'" <br />/ <br />� I51 <br />CONTRACTOR ADDRESS <br />\ CITY/STATE/ZIP 1 7_+('� <br />r- <br />ti <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />C�l g C C V <br />LICENSE 6-57 <br />C-61 <br />F D-09 <br />Other <br />NUMBER ' J EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE omestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />1 Public WaterSystem <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 1 1 New Well C_ Replacement Well i Well Alteration/Modification I I Other <br />I Monitoring Well(s) # of wells I Soil Boringk of borings s) I I Geotechnical C�t <br />Out -Of -Service Well I Out -Of -Service Well Renewal I Cross -Connection Repair C <br />New Pum C Pum Replacement 7 Pum Repair 1 Raise Well CasingR��r^i� <br />WELL CONSTRUCTION Ono <br />B <br />Drilling Method I Mud Rotary _! Air Rotary i I Auger 1 Cable Tool Push Point I Other Na <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel STId'• J_ O�QW�bdUweetter <br />Well Casing D g 9 Depth It H�7}i pEP ENTqL <br />g iame erConductor Casing iThickness/Gaud) e/ASTM Sched ameter Conductor Casin D Steel Plastic ! Stainless Steel Other ARTMENT <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) i Sand Cement sack mix/7 gal water <br />I I Bentonite (20% solids) Other <br />Grout Placement Method i Pumped -1 Free Fall Other i Retardant -/ Accelerator (name) <br />PEDESTAL Installed By Driller I Pump Contractor I Other <br />1 Concrete Pedestal Dimensions: Width It Length ft Thick in i Christy Box i i Stove Pipe <br />PUMP xi SubmersibleiJ Turbine I Other HP Pump Set= ft Standing Water Level% ft <br />c <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 CALIFOR ONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE/1THLL <br />WORKERS C ION LAWS. <br />INIM 24 HO V N 4CE REQUIRED FOSPECTIONS -PLEASE CALL (209) 953- 6 <br />SIGNED TITLE i \ DATE <br />EP RTMENT USP O LY <br />Application Accepted By / Date <br />Grout Inspection By <br />Date <br />Pump Inspection By <br />Date Z <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />Well ID# <br />Area Employee ID#,N&* <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth It <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Qrlhaakop <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />3/7z> <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />