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NA <br /> WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186$EAST HAZELTON AVENUE-STOCKTON'CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOS ADDRESS o I VE'T c, i 4.� Je I CITYIZIP t f111 � <br /> CROSS STREET C '64 Y AP N } PARCEL SIZE 0'7'6""AND USE APPLICATION# � <br /> _ <br /> ! C1J <br /> m <br /> OWNER NAME PHONE �,74{/ — <br /> OWNER ADDRESS • ce, er - CITYISTATEIZIP 5 6,419 5Z ✓c <br /> CONTRACTOR 0- lyde%" PHONE u.'r <br /> CONTRACTOR ADDRESS tOZ Ti3 N4±r.G CITY/STATE/ZIP 1LvQ, `./� � <br /> /�/���Z <br /> SUBCONTRACTOR MA PHONE I"/1✓Q <br /> SUBCONTRACTOR ADDRESS N/4- CITYISTATEIZIP 11114 <br /> LICENSE )(C-57 C-61 D-09 Other NUMBER t (.' EXPIRATION DATE / ����✓+ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sam plinglCharacterization <br /> Public Water System <br /> 1 different from Owner: Water bystern Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ! Replacement Well Well Alteration/Modfication Other <br /> MonitoringWell(s) #of wells Soil Boring(s)3 #of borings #of borings <br /> ( ) g( ) :s{Geotechnical <br /> Out-Of-Service Well Out-Of-Service WeII Renewal i Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair __i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 7XMud Rotary Air Rotary Auger Cable Toa[ Push Point Other <br /> Proposed Well Depth5_ft Excavation — in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel Plastic i Stainless Steel Other <br /> Grout Seal Depth ft XNeat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) <br /> Grout Placement Method Pumped Free Fall Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By Driller . Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length It 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 /> MIN U �24 HOUR CE NOTICE REQUIRED FOR <br /> saINSPECTIONS <br /> � - PLEASE CALL(209) 953--7697 <br /> SIGNED TITLE//r c 8L int �{A !!��(�+�'Di DATE CS <br /> 1' <br /> A _P11 <br /> V�e <br /> l rj <br /> - rL <br /> Q <br /> 4 <br /> E 1- <br /> �ryT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By C Date ,,,, Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date L WAIVER Received <br /> Soil Baring Inspectio y — ate 3 —141, Constructed Well Depth ft <br /> COMMENTS G L f Lc <br /> 3rX�? 7 22 fie_ <br /> PE SC Received heck Amount Date Permit! Invoice# Well ID# <br /> Codes Info B S Remitted Service Request# <br /> q57 I.O '--Z/o3 <br /> EHO 43-06 WELL/PUMP PERMIT <br /> 4130112 <br />