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v <br />WELUPUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />..r._n a vim. • r% 11 an <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS k X, t \-.G tX ✓\ <br />CROSS STREET <br />OWNER NAME n <br />OWNER ADDRESS � .'(j t�� <br />CONTRACTOR V o <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR `^ <br />SUBCONTRACTOR ADDRESS <br />LICENSE ?. C-57 <br />C-61 I D-09 <br />CALL (2U9) 9b3 -/b9/ FUH INbPtt„I IUNb nw I r �... --- <br />APN1PARCEL SIZE LAND USE APPLICATION <br />AD iD ?A <br />PHONEywty u� ms PHONE <br />���� CITY/STATE/ZIP <br />Other l.Ja1*� WL'tC�/�'/' NUMBER6'G k/G EXPIRATION <br />3EOGRAPHICALINFO MATION: Coordinates X Y lownsnip mange bectlon <br />NTENDED USE omestic/Private C7 Irrigation/Agricultural U Industrial Ci Water Quality Monitoring U Soil Sampling/Characterization <br />[ I Public Water System <br />If different from Owner: Water System Name tact ame or Phone umber <br />TYPE OF WORK Fi New Well [1 Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) If of wells U Soil Boring(s) # of borings ❑ Geotechnical <br />U Out -Of -Service Well U Out -Of -Service Well Renewal U Cross -Connection Repair <br /># of borings <br />❑ New Pump APump Replacement U Pump Repair ❑ Raise Well Casing <br />s <br />WELL CONSTRUCTION <br />Drilling Method U Mud Rotary ❑ Air Rotary C Auger U Cable Tool CI Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom [-I Gravel Pack/Gravel Size in diameter <br />u Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel U Plastic C Stainless Steel U Other <br />Grout Seal Depth ft [l Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br />I Bentonite (20% solids) � 1 Other <br />Grout Placement Method i -I Pumped '� Free Fall r Other L Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller .7 Pump Contractor ❑ Other <br />Concrete Pedestal CDimensions: Width ft Length ft Thick in ❑ Christy Box R Stove Pine <br />PUMP submersible❑ Turbine I; Other HP =_1„` Pump Set ft Standing Water Level ft <br />1 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 />MI IIAUVNHPURA VANCE NOTICE REQUIRED FOR SPECTIONS -PLEASE CALL (209) 953-7p97 <br />SIGNED TITLE l lS i DATE 1- k <br />_DEPARTMENT/ USE ONLY <br />Application Accepted By v Date <br />Grout Inspection By Date <br />Pump Inspection By , Date <br />Soil Boring Inspection By _ Date <br />COMMENTS <br />j wry <br />Area )` Employee ID#� <br />❑ SPECIALWell Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />LIL <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/Invoice <br />Service Request #7 <br /># <br />Well ID# <br />LJ f 00 _5431 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />