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WELUPUMP PERMIT <br />SArh JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-HEFUNDABL�E%PERMIT <br />Sc <br />Info <br />CALL ZUy y53 -f 10 i/ FOR IN5PhU I IUNS <br />1 T CAn rnvivl vm i c �aavw <br />JOB ADDRESS 23� <br />p <br />/ • Jyhn sem, <br />CITY/ZIP (�'4- <br />/r_ANrInF_Q <br />//w,�P 19!;;?;) <br />CROSS STREET L <br />APN O23 /DU Z3 <br />PARCEL SIZE 6 y <br />LAND USE APPLICATION If <br />OWNER NAME <br />i► <br />OWNER ADDRESS � <br />(n�� <br />'fl <br />CITY/STATE/ZIP <br />CONTRACTOR <br />CONTRACTOR ADDRESS ����` <br />�P �"' <br />CITY/STATER T-7 <br />HONE <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE C 57 ] C-61 <br />7 D-09 <br />0 Other <br />NUMBER 3) Q ) 7 <br />EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE U Domestic/Private Irrigation/Agricultural ❑ Industrial Ci Water Quality Monitoring U Soil Sampling/Characterization <br />[l Public Water System <br />If different from Owner: Water System Name tact Name or Phone Number <br />TYPE OF WORK )( New Well [1 Replacement Well ❑ Well Alteration/Modification 0 Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />I I New rump rump Hepiacement a rump Hepair U Haise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method �P ud Rotary [7 Air Rotary ❑ Auger�216 <br />Cable -/1 Cl Push Point 0 Other <br />Proposed Well Depth ft Excavation I dia eter X Open Bottom U Gravel Pack/Gravel Size in diameter <br />U Conductor Casing AVA' in diameter / Conductor Casing Depth k <br />Well Casing Diameter'in�j�fhickness/Gauge/ASTM Sched vZO XSteel ElPlastic C Stainless Steel 0 Other <br />Grout Seal Depth /00 t ft 1 Neat Cement (94 Ib bag/5-10 gal water) Sand Cement -Z sack mix/7 gal water <br />J Bentonite (20% solids) 1 Other <br />Grout Placement Method Pumped n Free Fall F. Other 11 Retardant / Accelerator (name) <br />PEDESTAL Installed By Drillar Pump Contractor 0 Other <br />Concrete P destal FDimensions: Width ft Length ft Thick in 11, Christy Box n Stove Pipe <br />PUMP I -I Submersible[! Turbine f ; 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 AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINI UM 24 HOU �VANCE NOTICE REQUIRED FO IINSPE TIONS - PLEASE CALL !2041 4S'%-7SCI7 <br />SIGNED �.f/G� TITLE l LY /.0 DATE /�,��' `� <br />v DEPARTMENT USE ONLY <br />Application Accepted By Date I V 'Z S _0 Area I Employee ID# <br />Grout Inspection By Date , 0 SPECIAL Well Permit <br />Pump Inspection By Date 0 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Dep h 2 -5 - <br />COMMENTS Tr CA S ferr u v✓1 0l 3 SV 3.-hn3 c (S R O G 3� y <br />-r'o,-.Irn r-7 ZiLi/. /7 kO -- I.• ! n , IILI <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date Permit/ <br />Service Request # <br />Invoice WeIIID# <br />LI3O <br />I rL> <br />3f <br />LO5 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />I1 <br />