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r 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 /> 0LOAJOB ADDRESS 77 —�'---,�em � I FSP-- CITY/ZIP �Q�lT- G"A C75 Z!~ v <br /> CROSS STREET �✓t SA APN l�L' -7F nPARCEL SIZE LAND USE APPLICATION If m <br /> OWNER NAME - q < v PHO�NE/ v' `✓L'����/ N <br /> OWNER ADDRE09, <br /> O CITY/STATE/ZIP �► �/ /�'�� <br /> CONTRACTORL PHONE. <br /> ( /� <br /> 212 t <br /> CONTRACTOR ADDRESS _ � CITY/STATE/ZIP <br /> SUBCONTRACTOR // � 7 �' `s-��� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE XX-57 )IOC-61 I D-09 (I Other NUMBER EXPIRATION DATE / <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE >Vbomestic/Private P Irrigation/Agricultural 0 Industrial ; Water Quality Monitoring U Soil Sam piing/Characterization <br /> U Public Water System <br /> If different from Owner: Water System Name fact ame or Phone umber <br /> TYPE OF WORKew Well II Replacement Well ❑ Well Alteration/Modification 1) Other <br /> /❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings E Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> Mew Pum r' Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,)(Nud Rotary 0 Air Rotary Cl Auger ❑ Cable Tool U Push Point 0 Other <br /> Proposed Well Depth -7�p _ft Excavation - /7— in diameter '-] Open Bottom ravel Pack/Gravel Size in diameter <br /> U1 Conductor asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in hicknesslGauge/ASTM Sched���J U Steel ❑ Stainless Steel 0 Other <br /> Grout Seal Depth ft I V�CI Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> 1 Bentonite(20%solids) �i Other <br /> Grout Placement Method umped '-1 Free Fall 11. Other 11 Retardant/Accelerator(name) <br /> 01 <br /> PEDESTAL Installed By U Driller 7 Pump Contractor ❑ Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box n Stove Pipe <br /> PUMP ubmersibleU Turbine I; Other HP Pump Set .7 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 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 COMPEN ION LAWS, <br /> MIVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)959-769 <br /> SIGNED TITLE d0.f0"-I DATE <br /> S <br /> q <br /> i i HIT--- <br /> Tj) I)- <br /> P O C <br /> E_7.R U E NLY <br /> Application Accepted By Date Areaq-lqq Employee ID# <br /> Grout Inspection By MI Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date _ Constructed Well Depth ft <br /> COMMENTS _ <br /> PE SC Receivedhe # Amount Date Permit/ Invoice# Well ID# <br /> Codes Info 8 s Remitted Service Request# <br /> 4s 70 <br /> /517DzR <br /> E 043-Ori WELL/PUMP PERMIT <br /> 4/30/12 <br />