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4 <br />- 6a1 Sian �I��eliS t� 'lav=G <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT (:ALL (ZU9) UO3-/bUf FOR INSPEG I IUN5 %r_Arrntw r i cHn rnvivi wm i r-'7awry <br />JOB ADDRESS /3 /— ���/// // ,l CITY/ZIP <br />CROSS STREET I ,%� , Ir ,, s n ,( APN I "t Iy1 V f� �/ PA,R�CIEL SIZE •_LAND USE APPLICATION # <br />OWNER NAME lam. L AP_ 1,- 111 , M lrhn } a 1V� lI � HONE 209 y�y`%—C� 3 <br />OWNER ADDRESS <br />CONTRACTOR <br />C.i <br />'fig Bax gel l f=%t`l7�i" <br />CITY/STATE2IP <br />CONTRACTOR ADDRESS e;�elzr SLI /L /7 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE X C-57 !I C-61 i) D-09 H Other <br />NUMBER <br />PHONE 6Gs–/ 77Z Z - -2-75--7 <br />2 -7 - 7 <br />CITY/STATE/ZIP� �i g e17 ! c �/ :2 `yz <br />PHONE <br />CITY/STATE2IP <br />EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE /' Domestic/Private 0 Irrigation/Agricultural ❑ Industrial Ci Water Quality Monitoring U Soil Sampling/Characterization <br />T1 Public Water System <br />If different from Owner: Water System Name-------- Co—niact Name or Phone Number <br />TYPE OF WORK F1 New Well )�Replacement Well ❑ Well Alteration/Modification <br />0 Monitoring Well(s) If of wells ❑ Soil Boring(s) <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewa <br />❑ Other <br /># of borings `, Geotechnical <br />I ❑ Cross -Connection Repair <br /># of borings <br />4 ivew rump L rump neplacemem a rump Hepalr a Halse wen Uasing <br />WELL CONSTRUCTION <br />Drilling Method (Mud Rotary ❑ Air Rotary c Auger U Cable Tool U Push Point ❑ Other <br />Proposed Well Depth/24ft Excavation 2 in diameter _) Open Bottom Gravel Pack/Gravel Size 3 f in diameter) <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched �% U Steel Plastic ❑ Stainless Steel 0 Other <br />Grout Seal Depth _�_ ft n Neat Cement (94 Ib bag15-10 gal water) Sand Cement sack mix/7 gal water <br />I Bentonite (20% solids) � ) Other <br />Grout Placement Method A Pumped :_) Free Fall 0 Other [! Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller , Pump Contractor ❑ Other <br />Concrete Pedestal „Dimensions: Width t Length �. S„" ft Thick in ❑ Christy Box 0 Stove Pipe <br />PUMP Submersible[) Turbine I; Other HP__2, 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 />_M_IN UM 2�4 H / V CE NOTICE REQUIRED FOR INSP CTIONS-PLEASE CALL (209) 953--799-7 <br />SIGNEDTITLE (i)/eIJ(,IWk,"_4 7 <br />DATE W3h / <br />Application Accepted BSC <br />Grout Inspection Sy <br />Pump Inspection By <br />Soil Boring Inspection By <br />DE ARTMENT SJ ONLY <br />Date <br />Date 7i <br />Date 0 <br />Date <br />TLI <br />r"0E,NT <br />Area Employee ID# (A7 <br />0 SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed 1JVell Depth ft! <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />heck#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />_ <br />rI0031WI I <br />%' DU -7 7/ 3 L <br />EHD 43-06 <br />4/30/12 <br />WEI.L,PIRdP PEnMIT <br />