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f <br />scan W4 <br />1, <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS t�rlrs�a I T tAAK I -HUM UA I t 110ODUCU <br />JOB ADDRESS 3�7'-J / I�l e o �j I CITYCITY/ZIP�� L IP _��kll 4257(C/1� <br />CROSS STREET 1��7A' j wl- APN I"`/, I- 070 - // PARCEL SIZE •� LAND USE APPLICATION If <br />OWNER NAME M� HONE20 <br />il% BnX $�11 rirr)�il u'rl s" <br />OWNER ADDRESS 2 CITY/STATE/ZIP-7,yiY% -7�/¢ i�zriG. <br />CONTRACTOR S/1 O2L LL /i%� ��%G _ PHONE 6L/ / / 7 Z - z ? 5- 7 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE X C-57 ' 1 C-61 i) D-09 [l Other <br />NUMBER <br />CITY/STATE/ZIP { oz -1v S�%p a-_-7yz <br />PHONE <br />CITY/STATE/ZIP <br />EXPIRATION DATE4� <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE jy( Domestic/Private C Irrigation/Agricultural U Industrial [_, Water Quality Monitoring U Soil Sampling/Characterization <br />[l Public Water System <br />If different from Owner: Water System Name-------- Contact Name or Phone um er <br />TYPE OF WORK Fi New Well X Replacement Well ❑ Well Alteration/Modification 11 Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) If of borings _, Geotechnical # of borings <br />❑ Out -Of -Service Well U Out -Of -Service Well Renewal U Cross -Connection Repair <br />New Purnp Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method � Mud Rotary C; Air Rotary C Auger U Cable Tool Cl Push Point ❑ Other <br />Proposed Well Depth 12 _ft Excavation Z I in diameter Open Bottom Gravel Pack/Gravel Size 3 / in diameter <br />U Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 21 U SteelPlastic❑ Stainless Steel ❑ Other <br />Grout Seal Depth529 _ft Cl Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mW7 gal water <br />[_I Bentonite (20% solids) 11 Other ' l <br />Grout Placement Method ' Pumped I-1 Free Fall F], Other 11 Retardant / Accelerator (name) <br />PEDESTAL Installed By ADriller Pump Contractor U Other <br />Concrete Pedestal ;- Dimensions: Width 'ft Length j/. S= ft Thick in ❑ Christy Box r Stove Pipe <br />PUMP Submersiblet 1 Turbine I ; Other HP ==4==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 />MIN UM 24 H /V CE NOTICE REQUIRED FOnR/rIIN�tSP (CTIIyONS L- PLEASE CALL (209)19/5/3--7 97 <br />SIGNED � 1. TITLE _0, y J(_1' 4_0 TGt1-4 DATE 'I / /[ 7 <br />Application Accepted BSC <br />Grout Inspection -By <br />Pump Inspection By <br />Soil Boring Inspection By <br />DEARTMENT S ONLY <br />Date <br />Date 7i <br />Date <br />Date <br />T <br />Area Employee ID#' <br />❑ SPECIAL Well Permit J <br />❑ WAIVER Received <br />Constructed VVell Depth ft, <br />PE <br />Codes <br />SC <br />Info <br />Receivedheck#/ <br />By <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well !D# <br />0 V <br />UD <br />ILA <br />t� <br />a� »t3; <br />W 00 3 O <br />I <br />1LOYJ7 7/ 34, <br />EHD 43-06 <br />4/30/12 <br />WEI.L,PUMP PERMIT <br />