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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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> m <br /> J08 ADDRESS !- CirrlLlP D <br /> CROSSSTREET '�p0 S APN lU 3 2 2 c <br /> PARCEL <br /> ARCEL SIZE �-1 ^�LAND U�SE APPLI,CAYA,T,I1O,N1/# <br /> OWNERNAME Ai)±us `) PA/ too Naa /hLYo PHON '40 <br /> /I� <br /> MP <br /> OWNER ADDRESS Qq -/ 2- CITY/STATE/ZIP <br /> CONTRACTOR 0 V1lKyiki OVA HONE L/A <br /> 44 �d f tJ"0 �bCONTRACTOR ADDRESS Y <br /> STATEIZIP <br /> SUBCONTRACTOR 14 Y't PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 7 <br /> LICENSE C-57 L C-61 U D-09 U Other NUMBER — EXPIRATION DATE <br /> 1 1 �O 1 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private ]Irrigation/Agricultural ❑Industrial ]Water Quality Monitoring C Soil Sampling/Characterization <br /> U Public Water System <br /> If different from Owner. water SyStern Name on ac Name or 11none NUMber <br /> TYPE OF WORK thNew Well L Replacement Well U Well Alteration/Modification U Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of bongs ❑Geotechnical of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> U New Pump L Pump Replacement U Pump Repair U Raise Well Casing <br /> WELL CONSTRUCTIONodTIY <br /> Drilling Meth (]Mud Rotary C Air Rotary C Auger ]Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth_3�ft Excavation 2 in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter <br /> f1 Conduc r Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diamet I kness/Gauge/ASTM Sched f1 Steel f1 Plastic nStainless Steel -1 Other <br /> Grout Seal Dept _ft E Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/]gal water <br /> B tonne ° ids) L Other <br /> Grout Placemen Method Pumped 0 Free Fall C Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ]Driller Ilif Pump Contractor ] Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in U Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible]Turbine E Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY RTI HAT 1 HAV PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOA 0 N RDINANC STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CUR TAD CT E W E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WO OM WS. <br /> 24 H C i; IRED FOR INS1P^E'CTI NS--PLEASE CALL <br /> EASECALL(209)9 3-7697 <br /> SI ED TITLE, �1f`"�-T �D• ' � �'1' DATE <br /> ` ?01/ <br /> O <br /> I OuN�, <br /> TIAL <br /> MENTI <br /> DEPARTMENT U E O LY ��/ /y�/7� <br /> Application Accepted B Data -7 7 Areae Employee ID#��' { V <br /> Grout Inspection By / Date 7 / ❑ ECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Dat C nstructed Well Depth ft <br /> C MivLE ITS d <br /> PE Sc Received Check#/ Amount Date ermiU Invoice# WeIIID# <br /> Codes Info B Cash Remitted Service R uest# <br /> EH D 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />