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Aj:- A �s <br />aa:' ii.� <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT 1^ - CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />v <br />JOB ADDRESS ka "� D'1 "W j N(�'- CITY/ZIP ''t n a ff r I 9 J� �(, <br />CROSS STREET !V - SV) <br />e' I <br />Ve 1 'M (k -7 d 3U G I PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME <br />Y) <br />,AAPNN <br />� o U r i 1 l- ` <br />�^� <br />-� G / — 1-7 y G <br />G{�('� <br />OWNER ADDRESS 1 V <br />�/cA <br />-90 <br />O R � . R Q• <br />(.PHONE <br />CITY/STATE/ZIP v q I 121 A �^J5 <br />CONTRACTOR c <br />I� <br />\ <br />r I 1 I <br />/'C <br />PHONE ((,-cI <br />7q <br />/Z 1 <br />CONTRACTOR ADDRESS <br />CONTRACTOR <br />' <br />_ ]r^ /7 <br />CITYISTATE/ZIP v`11 1 , c A LI 5 G- 9 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE )Q C-57 <br />C-61 <br />i D-09 Other <br />2 <br />NUMBER 9 3 EXPIRATION DATE 7- 3 � <br />q 3 <br />ZLLP Ln <br />0 <br />V <br />�W <br />aW E0 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />INTENDED USE Domestic/Private .Irrigation/Agricultural I Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water 6ytenn Nam Gont.Ct Nam or P re um r <br />TYPE OF WORK New Well Replacement Well Well AReration/Modification Other <br />Monitoring Well(s) # of wells Soil Bodng(s) # of benngs Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method /"Mud Rotary I Air Rotary I Auger -i Cable Tool 1 Push Point i Other <br />Proposed Well Depth 440 ft Excavation1— in diameter 1 I Open Bottom �K Gravel Pack/Gravel Size 14 4 _ in diameter <br />-I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schede I 9w -1 Steel 'A Plastic 1 Stainless Steel I Other <br />Grout Seal Depth ri(; ft I Neat Cement (94 lb bag/5-10 gal water) j(Sand Cement sack mix/7 gal water <br />i Bentonite (20% solids) I Other <br />Grout Placement Method K, Pumped I Free Fall I Other I Retardant / Accelerator (name) <br />PEDESTAL Installed By ADrillef Pump Contractors I_ Other <br />XConcrete Pedestal Dimensions: Width ft Length ft Thidcin Christy Box Stove Pipe <br />PUMP ASubmersible- Turbine - Other HP Pump Set C) ft Standing Water Level L14U 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 �J �24 H/O/UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED :ice=F- a V"t I w, TITLE �3 CC 1 •rP-S • DATE J 15 <br />11 <br />OM q%- <br />ldkA <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE ,ONLY <br />ate ( Z j !P <br />Date l <br />Date f�l k fij <br />Date <br />F? <br />Area 0 "i Employee ID# <br />I SPECIAL ell Permit <br />I WAIVER Received <br />Constructed Well Depth ft <br />EHD 43-08 WELL /PUMP PERMIT <br />4/30/12 <br />7,12, <br />