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A <br /> / <br /> • WELUPUMP PERMIT <br /> SAWJOAC4J!N 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 Ln <br /> JOB ADDRESS V i►V&!`� CITY/ZIP m <br /> a <br /> -- v <br /> CROSS STREET k A..��//����yyPN- ` D06; - y`��LJ PARCEL SIZE `l�Zd�LAND USE APPLICATION#�r�f, m <br /> Cn <br /> OWNER NAME I.MVfi47W7 tN/C / ,PHONE _-2�, <br /> OWNER ADDRESS S CITY/STATE/ZIPbul� IU� <br /> CONTRACTOR ��/- lL PHONEn�yE� lL/7Z A�l��*�l✓� <br /> CONTRACTOR ADDRESS �T�CJ �� 1 � ,} CITY/STATE/ZIP <br /> SUBCONTRACTOR /�)/LL�i� 7 P�� � �/E—_t5 �PHHOONE1� [/���'/� !�pr� L(CJ <br /> SUBCONTRACTOR ADDRESS �tJCJ C IDP L.�VVV -CII]TY/STATE/ZIP 1�rkb AIV Y � !S11 <br /> LICENSE C-57 C-61 1 1 D-09 I Other NUMBER_/�M3— EXPIRATION DATE :F' 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 Contact Name or Phone Number <br /> TYPE OF WORK ew Well Replacement Well Well Alteration/Modification i Other <br /> 1 1 Monitoring Well(s) #of wells Soil Boring(s) _ #of borings Geotechnical n of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal 1 Cross-Connection Repair <br /> New Pump 1 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 DepthjVS— _ft Excavation 'Z (V in diameter Open Bottom Gravel Pack/Gravel Size `% in diameter <br /> XConduc.tnr Casing ZV in diameter / Conductor Casing Depth 2!C> ft <br /> Well Casing Diameter ✓ . in Thickness/Gauge/ASTM Schad Steel 1 I Plastic -Stainless Steel I Other <br /> Grout Seal Depth ?�J ._ _ft Neat Cement(94 lb bag/5-10 gal water) 1 Sand Cement l� sack mix17 gal water <br /> Bentonite(20%solids) Other_ <br /> Grout Placement Method umped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller >Qump Contractor Other <br /> Vl Concrete Pedestal➢Dimensions:Width__q It Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersiblek urbine Other HP tAr 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 CO P NSATI <br /> MI A ANC (NOTICE REQUIRED FOR\IWECTIONS- PLEASE CALL(209)9 3-7 97 <br /> SIGNED TITLE V DATE '� <br /> r N <br /> 2 <br /> U <br /> 30 <br /> E - <br /> _ I <br /> lit-- - -- — —.—. - -- <br /> GEPARTIME:NT U, 3E :yNLY <br /> Application Accepted By / Date Area' k` Employee ID# ` r <br /> Grout Inspection _ ( Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS G n — �c- �%L/' % <br /> z e i T rr� 5717Z5 < A-r .4,4 �✓� - <br /> PE SC Received Check Amount Permit/ <br /> Codes Info B = ash Remitted Date Service Re uest# Invoice# Well ID# <br /> A�& �SO j 23 �4 1`� � � r S(z� �y 9, �v Poo3�2q�i <br /> ns� 3763 s 3 <br /> E H D 4 3-06 4E:-7(f 41a U / 7- /xti WELL/PUMP PERMIT <br /> 4/30/12 <br />