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il/ 6 2 5 <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT ' GALL (ZU9) 9bJ-/0',i/ FOH INSPtGIIUNS cArrnca I > C++n rnvm Loma �JJVGV <br />/ /1 �} `I 53b� <br />JOB ADDRESS L Z..Z- 14w ✓�j /�� % CITYnIZIP I IDO '7 <br />CROSS STREET /'�//, - APN`f 9-Ov/% V ` PARCEL SIZE (�/I r72 LAND USE <br />APPLICATION <br />/#► <br />OWNER NAME Z'ro Pt -Ir 1 (-C G jey-�p PHONE / �� Zoz <br />OWNER ADDRESS 0, &,Y-, 113 7 CITY/STATE/ZIP941q44&--­_ ef 9-4-2© / <br />- <br />CONTRACTOR jj CL PHONE Z <br />��..,, <br />CONTRACTOR ADDRESS l _ CITY/STATE/ZIP Welle4a eA 2AV— 7 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ItXC-57 17 C-61 1 D-09 H Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER ��s�R� ? EXPIRATION DA <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE Domestic/Private F Irrigation /Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />I I Public Water System <br />If different from Owner: Water System Name-------- C-o—ntact Name or Phone Number <br />TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification 0 Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) _ a of borings Li Geotechnical a of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump Pump Replacement ❑ Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method XMud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth Z}Q_ft Excavation 42 in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter <br />❑ Conductccor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diamete inT ickness/Gauge/ASTM Sched .200 (1 Steel---61astic 0 Stainless Steel 0 Other_ <br />Grout SealDep Cl Neat Cement (94 lb bag/5-10 gat water) 11Sand Cement sack mix/7 gal water <br />toni o solids) � I Other <br />Grout Placement Method Pumped ❑ Free Fall P. Other U Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller (Pump Contractor ❑ Other <br />Concrete Pedestal i-Dlmehsions: Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br />PUMP I Submersibleu Turbine 11 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 />MINIIIIIUM 24 tH�OU� RA, /DJVANCE NOTICE REQUIRED FOR <br />INSPECTIONS - PLEASE CALL (209)J953-7697 / <br />SIGNED L V ►' 1. GLDCiCi TITLE DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By Date ❑ <br />Soil Boring Inspection By <br />AMENTS 911L —14t., <br />Date <br />1 -1 L Employee I <br />SPECIAL Well Permit <br />WAIVER Received <br />Well <br />ft <br />?z <br />m <br />D <br />v <br />v <br />M <br />m <br />rp <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />ChaqkW <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />3 <br />�3� <br />3fp <br />11 full(p <br />SCROQ-7V,80 <br />(V52-� <br />'R.2 51�dcj <br />m <br />_7103-60 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />