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- WELUPLIMP PERMIT <br />SAI4'�,JOAaUi'.• COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVVIV-''ithUNUAt6LtJFs�tiiMlryl <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS 91<41t <br />CONTRACTOR <br />CONTRACTOR ADDRESS 1 `• Gyl ` -) <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />L;ALjL (ZUjU) blt)J-111591 FOR INSPECTIONS EXPIRES 1 YEAR <br />RRj3FROMM DATE ISSUED <br />CITY/ZIP � � 4C <br />APN (] D PARCEL SIZE LAND USE APPLICATION # k <br />PHONE 4/0-L- - !-7 -LO V <br />LICENSE XC -57 I C-61 i i D-09 i Other. <br />I <br />C/` `` __ <br />-4 <br />CITY/STATE/ZIP <br />�,/PHHONE 3� Y'~ Y � LJ <br />CITY/STATE/ZIP lJ✓ OQDUI`kr <br />PHONE <br />CITY/STATE/ZIP <br />c C-14 <br />` <br />NUMBER �v EXPIRATION DATE b ` 1 4 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y _ Township Range Section <br />INTENDED USE omestic/Private I Irrigation/Agricultural I industrial LI 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 ❑ Replacement Well C Well Alteration/Modification i Other <br />1 i Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings I Geotechnical # of borings <br />Out -Of -Service Well ❑ Out -Of -Service Well Renewal I_ Cross -Connection Repair <br />>�New Pump Pump Replacement ❑ Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method rMud Rotary Air Rotary i Auger ❑ Cable Tool I i Push Point i Other <br />Proposed Well DepthS,:;O ft Excavation _J1„ in diameter Open Bottom i i Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter -6—in Thickness/Gauge/ASTM Sched I—ID i Steel ilQlastic I Stainless Steel ! Other <br />Grout Seal Depth-/,�_0ft I Neat Cement (94 Ib bag/5-10 gal water) Sand Cement_���i3 sack mix/7 gal water <br />Bentonite (20% solids) I Other <br />Grout Placement Method , I Pumped i Free Fall I Other Retardant / Accelerator (name) <br />PEDESTAL Installed By >Qriller I Pump Contractor I , Other Q /' <br />I Concrete Pedestal ' Dimensions: Width �L9— ft Length U ft Thick Q in I Christy Box Stove Pipe <br />PUMP be Submersible I Turbine Other HP Pump Set ft Standing Water Level ft <br />1 HEREBY CERT!FY 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!^":S. I ALSO CERTIFY THAT PAY RF?LIIRED 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 />MINIM M HOYR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED �c�rt� TITLE/ DATE P`1 9— if <br />.: 1 <br />m <br />n <br />0 <br />0 <br />rn <br />m <br />M 16 <br />Iq; <br />DEPARTMENT USE ONLY <br />Application Accepted By Date -131.1-91 1-5 Area -0 Employee ID# � "L <br />Grout Inspection By a Date %Z / ❑ SPECIAL Well Permit <br />Pump Inspection By Date F1WAIVER Received <br />Soil Boring Inspection By <br />rnnnf•=NTS(,, <br />Date /CIonstructed Well Depth <br />iA 1A <br />ft <br />PE <br />SC <br />Received <br />Check <br />Amount Date Permit/ <br />Invoice # <br />Well ID# <br />Codes <br />Info <br />By <br />Remitted Service Request # <br />-A3'7P <br />SC-> <br />/Z —F <br />3Ll 1 L j 8 g/�ey AtAlimVJ <br />DU3(p3(115 <br />2 I <br />E H D 4306 /L/,%/ i- E�'rv+%�- 56.�'e-�.o"bOI-Ar-1 fJ7ip /L -C5 -14i -13;�- WELL /PUMP PERMIT <br />4/30/12 <br />