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WELUPUMP PERMIT <br />` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT CALL (ZU9) 953-lbUt FOR INSPECTIONS tXPIRtb 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1301 A&.1a 241 �Q CITY/ZIP <br />CROSS STREET 0 / /&_,efe-t APN DU q 01 <br />Z- _/b PARCEL SIZE -LAND USE APPLICATION # <br />OWNER NAME ! ` <br />•G�I� <br />PHONE <br />he <br />Cas <br />f) <br />OWNER ADDRESS 5 ��� <br />` �7 %� <br />L' j41jL&,,4 L GP / 6 I/ On <br />V' Tj _ <br />/ CITY/STATE/ZIP <br />Invoice # <br />CONTRACTOR��L <br />�[ �i.7 /✓JC <br />PHONE <br />CONTRACTOR ADDRESS % <br />/ <br />SL c�h d�/O� i Q�f <br />CITY/STATE/ZIP <br />V Ali <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE )CC -57 C-61 D-09 Other <br />CITY/STATE/ZIP <br />NUMBER ` ;VA . EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE K Domestic/Private i Irrigation/Agricultural i Industrial i1 Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name ontact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well IWell Alteration/Modification I Other <br />or <br />i Monitoring Well(s) # of wells i i Soil Boring # of borings s) Geotechnical <br />Out -Of -Service Well i Out -Of -Service Well Renewal I Cross -Connection Repair <br />11-wm'PUT11P y, Pump Replacement Pump Repair Raise Well Casinq <br />Drilling Method Mud Rotary i i Air Rotary 1 1 Auger i 1 Cable Tool 1 ! Push Point i Other SAN JO !•uVr,, <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel S OAI p0 I�t r <br />Conductor Casing in diameter / Conductor Casing Depth ft PARTA46W <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft i Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mW7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />( PEDESTAL Installed By Driller X Pump Contractor Other <br />Concrete Pedestal Dimensions: Width 47/ j_ ft Length y• ft Thick in Christy Box i Stove Pipe <br />PUMP Submersible I Turbine 1 Other HP / Pump Set f6) ft Standing Water Level—&,/7— 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 />EP j R T M E N T U F, E N�Y <br />Application Accepted By Date Area Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />he <br />Cas <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Well ID# <br />650 <br />V Ali <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />