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WELUPUMP PERMIT <br />S.,v -"OAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON•VIEFUNDABLE PERMIT g j/ CALL 209 953-7697 FOR INSPECTIONS tXFJKI: 1 YEA FROM L)Atr Issutul <br />Joe ADDRESS _ CITY/ZIP _ �/T g51�I V <br />CROSS STREET 7=f�A{P�N -?-So'- O&O-C)� PARCEL SIZE C) SdLAND USE APPLICATION # <br />OWNER NAME J ff�/` /[i �� "/�iV �y PHONE 51 3/^ <br />OWNER ADDRESS <br />CONTRACTORot,��iilR/ Z NC' t3 / '- PHONE ;�151­3A% <br />CONTRACTOR ADDRESS ��! �1 �"G��1^�dI-�d CITY/STATE/ZIP <br />SUBCONTRACTOR STV ��/' (C��f` � OG Vi_a PPHHONE > z <br />SUBCONTRACTOR ADDRESS B/ /b � ��/ CITY/STATE/ZIP <br />LICENSE Xk-57 j6t-61 -I-) D-09 Cl Other_ NUMBER 7,fEXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />Township Range Section <br />INTENDED USEomestic/Private C:' Irrigation/Agricultural ❑ Industrial C; Water Quality Monitoring 1iSoil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name-------- Co_ntact Name or Phone Number <br />TYPE OF WORK lew Well Il Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) of borings L Geotechnical # of borings <br />❑ Out -Of -Service Well U Out -Of -Service Well Renewal U Cross -Connection Repair <br />jkfNew Pump rI Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method U Mud Rotary ❑ Air Rotary ❑ Auger U Cable Tool U Push Point ❑ Other <br />Proposed Well Depth_ B�� ft Excavation / 2- in diameter ❑ Open Bottom 'JUGravel Pack/Gravel Size in diameter <br />U Conduct <br />ol G�asing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in TT"hiicckness/Gauge/ASTM Sched 44 Z� [_l Steel ��Plastic C Stainless Steel ❑ Other _ <br />Grout Seal Depth Ll `Cl Neat Cement (94 Ib bag/5 10 gal water) .and Cement ,/Lp, sack mix/7 gal water <br />Bentonite (20% solids) [J Other _ <br />Grout Placement Method)dPumped :D Free Fall ❑ Other U Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller Pump Contractor Other <br />Concrete Pedestal _ mensions: Width ft Length ft Thick in D Christy Box I, Stove Pipe <br />PUMP VSubmersible (I Turbine f ; Other HP_ Pump Set ft Standing Water Level -'t7 ft <br />I HEREBY CERTIFY THAT 1 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 />MIN _;�'!Z <br />2 H ANCE NOTICE REQUIRED FOR I�TIONS - PLEASE CALL (209) 953-769 <br />SIGNED '1__ TITLE Q� DATE l - <br />DEPARTMENT USE ONLY <br />Applicai:on Accepted By-.uaie _ l L <br />Grout Inspection Z - Date <br />Pump Inspection By i Date Z <br />Soil Boring Inspection By Date <br />COMMENTS '4)-4Ab <br />1�_Z7i: l� u. !// -fp" <br />A <br />m <br />D <br />v <br />O <br />m <br />m <br />N <br />.S <br />Area_. / Enipluyee iD#•rte � ! <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />��-.�. �F, � ./G s'S ii)✓1�17� / �r� Pig <br />ZC s <br />ti (' L• <br />L� <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />WOO q VO <br />�3Sv <br />oso <br />Lf -36 3 <br />s3 ti <br />a <br />51200 7 S3 <br />OU W <br />EHL' 43 -CS <br />4/30/12 <br />WELL/PUMD .-ERMIT <br />