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WELUPUMP PERMIT <br />SAI^JOAQUO COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-`-iEFUNUABLE PERMIT CCALL ZU9 9b3-7697 FOR INSPECTIONS EXPIRE/S, 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS C7 ./ ,4 CITY/ZIP <br />CROSS STREETA/6" LC l� APN ZA 7 D21' 0 U �0 PARCEL SIZE 14 3 LAND USE APPLICATION #) k <br />OWNER NAME &J 7 �y�� [ l �" \ PHONE qO -L _ —7 •✓� V <br />OWNER ADDRESS f/( ih49 <br />CONTRACTOR A • - CU&l.</L / <br />CONTRACTOR ADDRESS 1 `• <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ZC-57 C-61 <br />D-09 I Other <br />CITY/STATE/ZIP <br />PHONE —53 �— 4j 7 2 S— <br />CITY/STATE/ZIP N <br />11 <br />PHONE <br />CITY/STATE/ZIP- <br />NUMBER 3 �� �v EXPIRATION DATE G-0 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y _ Township Range Section <br />NTENDED USE omestic/Private Irrigation/Agricultural industrial Water Quality Monitoring Soil Sampling/Characterization <br />i Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well i I Replacement Well I i Well Alteration/Modification <br />I Monitoring Wells) # of wells i Soil Boring(s) <br />Out -Of -Service Well ! Out-Ot-Service Well Renewa <br />i i Other <br /># of borings I Geotechnical <br />I Cross -Connection Repair <br /># of borings <br />i+VVew I--ump Fump me lacement 1 ' vump He air Raise Wen Gasin <br />WELL CONSTRUCTION <br />Drilling Method.Mud Rotary Air Rotary I Auger ! Cable Too] Push Point I Other <br />Proposed Well DepthS,,70ft Excavation _lam in diameter Open Bottom i Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter � ._� in Thickness/Gauge/ASTM Sched ZSteel Mastic I Stainless Steel I Other <br />Grout Seal Depth/JI'D ft Neat Cement (94 Ib bag/5-10 gal water) ><Sand Cement1sack mW7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By >triller Pump Contractor Other 0C <br />Concrete Pedestal Dimensions: Width ft Lengthy ft Thick Q in Christy Box Stove Pipe <br />PUMP yeSubmersible Turbine 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 REGULAT!C":S. I ALSO CFRTIFY THAT MY RFOU!RED 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 />MI IM M HOJJR ADVANCE NOTICE REQUIRED FOR I�N�/SPPEjCTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED `ipd�dL TITLE cgk& DATE R—I 9—,-f <br />1 <br />DEPARTMENT USE ONLY <br />Application Accepted By L Date 73 ( S <br />Grout Inspection By Date /2 <br />Pump Inspection By ti Date <br />Soil Boring Inspection By Date <br />rnnnrA-NTS I <br />Area -17 Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />1 / - - - . <br />to <br />M <br />D <br />v <br />0 <br />z <br />M <br />N <br />00 <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />By <br />Check <br />---r—ash <br />Amount Date Permit/ <br />Remitted Service Request # <br />Invoice # <br />Well ID# <br />431 <br />L <br />/Z2-F <br />341 IliS 8/� <br />W DU3(p U <br />dl <br />�)k-V3 <br />roo 3l0 s Q <br />2 I <br />EHD 4306 /L////f �'�v✓� L'v"�7wiy,%� ,;,ZV /-%5.f/, —7-- WELL /PUMP PERMIT <br />4/30/12 / <br />