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WELUPUMP PERMIT <br />P <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT .�. �L;ALL ((ZUUV,)) 1V53-7697 FOR INSPECTIONS tXF'IKtS 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS t '��r�� c2l. Vr 1yTLr--M MV Miliye CRY/ZIP Lax i rti5Z4 L <br />CROSS STREET VdAlt+s. JfM.�AYMiiwLli] 1��1,PINe Of CEL SIZE <br />�LAND USE APP-LfICATION# <br />OWNER NAME FCb tbmEs (/]1V 2 S ly PHONE y 25, 7(0�. 3545 <br />OWNER ADDRESS 10100 M9141 TV SWAN 1160)7020 CITY/STATEIZIP STLI[ IGTID14 I CA 4S2 f q <br />CONTRACTOR \ i W 1)06% F41' . 1 14 c PHONE 20 :4401 . 7700 <br />CONTRACTOR ADDRESS It -3-3, CITYISTATEIZIP GIpLr; crit 95 3 L <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE )ILC -57 C-61 D-09 <br />PHONE <br />C IIT1 4Y/SST�T• ATEIZZIP (� Q <br />Other NUMBER 0TP-1 EXPIRATION DATE • iw. 18, <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring oil Sampling/Characterization <br />Public Water System <br />If differem from Owner: Water SysteM e" (Jontact Nam or Phom Nwnber <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s)___ # of wells Soil Boring(s) If of borings (Geotechnical �� of bonny' <br />Out -Of -Service Well Out -Of -Service Well Renewal - Cross -Connection Repair <br />IKalse well <br />Drilling Method Mud Rotary Air Rotary XAuger Cable Tool - Push Point Other <br />Proposed Y'f8R Depth l D' Zo It II Excavation �/ in diameter -Open Bottom Gravel Pack/Gravel Size in diameter <br />Wt#!55 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel - Plastic Stainless Steel Other <br />Grout Seal Depth 10 -20 it XNeat Cement (94 lb bag/- 10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped $Z ee Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length It Thick in Christy Box StovePipe <br />PUMP Submersible 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 />JOA(A)IN COUNTY ORDINANCFS, ST4"I'7 LAWS, aVC RULES ANE REGULATIONS I ALSO CERTIFY THAT MY REOUIRED 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 />MINIMUM 24 HOUR ADD�YAN�C�EyJ1NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 7953-7697 <br />SIGNED I � ✓ • `J'V�`w�. TITLE S 1 A Fr eA11T W � DATE <1 S II P <br />AR_TMENT USE ONLY <br />Application Accepted By ate - S <br />]I/Gmtl� In pgc o By —nf�p�ate y <br />10 <br />Pump pec Date , <br />Soil Boring Inspecti n By Date <br />4 /h _ COtvjME S lw. <br />lj�/ (PE SCI Received heck#I Amount Date Permit/ <br />Codes Info B Remitted Service R u <br />14371J S/. 317D 1 `4311 S1 t.pr, o3� <br />JO, x:118 <br />MRo V CO <br />tHOEP � �Fv ry <br />T <br />Area I 1 cJ : Employee lD# <br />L SPECIAL Well Permit <br />L. WAIVER Received <br />Constructed Well Depth ft / <br />,r' d� r <br />hu <br />- I Invoice # I Well IDN <br />EHD 43.05 WELL /PUMP PERMIT <br />4/30/12 <br />