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/ <br /> • WELUPUMP PERMIT <br /> SAWOACOIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> r <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS a0 Oubiewy, CITY/ZIP n <br /> CROSS STREET 6zaRO APN '71 6.1 CZ*J PARCEL SIZE 1,5,2-40 LAND USE APPLICATION# m <br /> OWNER NAME WOMB/ , !A/e- PHONE 7�1- (S-It�j Woo <br /> OWNER ADDRESS S CITY/STATE/ZIPwo a-,-fUV l.- <br /> CONTRACTOR - !L PHONEZA�( <br /> (at <br /> CIT /STATE/ZIP ; 4#34j CONTRACTOR ADDRESS <br /> L 1�JL <br /> SUBCONTRACTOR � ]�//��� }� /�/i �0,- � � PHONE L�`r'J/ ( Q��0 LW <br /> SUBCONTRACTOR ADDRESS -700� LC bVVV CITY/STATE/ZIP /v Y l_ [ ul <br /> LICENSE C 57 C-61 D-09 Other NUMBER 77Y EXPIRATION DATE 31 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial 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 ew Well ! Replacement Well I Well Alteration/Modification 1 1 Other <br /> 1 Monitoring Well(s) #of wells Soil Boring(s) #of borings I Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth IVK ft Excavation (V in diameter Open Bottom Gravel Pack/Gravel Size YV& in diameter <br /> -;(,Conductnr rasing ZV in diameter / Conductor Casing Depth 2,,-> ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel i Plastic )Stainless Steel Other <br /> Grout Seal Depth '40 _ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement It 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 >Zump Contractor Other <br /> Wk Concrete Pedestal"imensions:Width q ft Length ft Thick in Christy Box 1 Stove Pipe <br /> PUMP Submersible Turbine i 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 ORDIN ES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND CTIVE H THE CALIF IA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CONSATI <br /> MI A ANCV NOTICE REQUIRED FOR <br /> I�ECTIONS- PLEASE CALL(209)973-7P97 <br /> SIGNED TITLE V DATE <br /> oal k's <br /> 2 " <br /> u <br /> �o <br /> i <br /> t✓ E PART M, EN I U 3 E ut LY <br /> Application Accepted By �I Date Area' Employee ID# 605' 1& <br /> Grout Inspection - l Date �� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constr cted Well Depth ft <br /> COMMENTS .CG7 <br /> PE SC ReceivedCheck Amount Permit/ <br /> Codes Info B sh Remitted Date Service Request# Invoice# Well ID# <br /> AzWk i lso AV,, 37623 y41L, Si20)17(-� g' VvPoo3�2q� <br /> �t csJ 37625 3 c W p 1� <br /> EHD 43.06 4:S:FC4.77 /�� WELL/PUMP PERMIT <br /> 4/30/12 <br />