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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT . k ALL (ZU`J) VDJ-(t)V( FOR INSPECTIONS tAVIKtS 1 YEAR FROM UATE ISSUED <br />JOB ADDRESS 29`15 W. NARNEy WAF—CfTY/ZlP ` Lto /952�F2. <br />CROSS STREET �I.DW�EQ-')F4RA�rO APN 0541 CM&I14, M ARCEL SIZE 05 LAND USE APPLICATION # /�Q� <br />OWNER NAMEyice tAOME n�(y.otw yL"y't'd Y -r �P/H�ONE 92-15•-7`�0' -WqS <br />OWNER ADDRESS 101W 1 �II`�ttiT-1� iA V.W,%j (SUN T!. qZo CRY/STATE/ZIP Slri C"41 CA 1352.19 <br />CONTRACTOR V AW t1lal(� •'��. PHONE '20. 'JO .-7 <br />CONTRACTOR ADDRESS 11'a3 `61&-Vkjv sr CITYISTATE/ZIP el PIL ICA 95IP3L <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE xC-57 C-61 D-09 <br />PHONE <br />CITY/STATE/ZIP <br />Other NUMBER -1207011 ExPIRATION <br />`i. 3o. / 8 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial -- Water Quality Monitoring (Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water 5ystem NaMe Conrad N.M. or ne Number <br />TYPE OF WORK - New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings _Geotechnical 3 of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary 4uger II Cable Tool Push Point Other <br />Proposed-VVMr Depth tO-20 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 1 D • 2,0 ft KNeat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped }Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <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 />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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)7953-7697 <br />rY•��/ <br />SIGNED K&A Aa ea e, TITLE STAFF ENh1n(EVK- DATE i/5/1P <br />EPARTMENT USE CINLY <br />Application Accepted By `'' .��p�yD�tate Q' jS ' (1 " <br />Grout Inspection By Vance W or� pyan 7J mate � �UJ - 1 o <br />Pump Inspection By Date <br />Soil Boring Inspectiorl By <br />Date <br />Area.t Employee ID# W G I"'- 1 <br />I SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received theSidV <br />Codes Info B as <br />Amount <br />Remitted <br />Date <br />Permit/ Invoice # Well ID# <br />Service Request # <br />gj4.1' 3 <br />43t1 <br />21,5118 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />