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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 /> I o� © rT'L�/Y CITY21P G� / S ?n m <br /> JOB ADDRESS }�- / / ��-�7 � 0 <br /> CROSS STREET /re 1 '`aac <br /> AP �l rI — PARCEL SIZE/LAND USE APPLICATION# m <br /> M '1 b /!�, <br /> OWNER NAME /_''Q/l � � r PHONE 7c)�� <br /> OWNER ADDRESS I-v-d o x <br /> b;LaCITY/STATE/ZIPV <br /> CONTRACTOR tOc Y M o i WOIT" J .-, CPPH'OvNE <br /> CONTRACTOR ADDRESS l/": O Jecl CITY/STATE2IPS&,e!e <br /> I Sac o <br /> Cn <br /> SUBCONTRACTOR / 4 S'C 1 1 joy-< LL 11,in( ' /y_P/HONE <br /> SUBCONTRACTOR ADDRESS 1 k 9' A 1((!b errs 41 <br /> CITY/STATE/ZIP / �4'rS 10C,4 �S J7 <br /> }d % fO EXPIRATION DATE <br /> LICENSE C-57 r l C-61 .1 D-09 C1 Other NUMBER <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE if Domestic/Private n Irrigation/Agricultural 0 Industrial G Water Quality Monitoring L Soil Sampling/Characterization <br /> I1 Public Water System <br /> If different from Owner: Water System Name contact ame or one umber <br /> TYPE OF WORK ,p New Well I 1 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) N of borings L Geotechnical #of borings <br /> 4'Out-Of-Service Well Ll Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> CI New Pump C' Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 4 Mud Rotary 0 Air Rotary C Auger Ll Cable Tool U Push Point 0 Other <br /> Proposed Well Depth cft Excavation - 1A in diameter ❑ Open Bottom �4 Gravel Pack/Gravel Size in diameter <br /> Li Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 � ,in Thickness/Gauge/ASTM Sched 30 �i Steel L-Plastic ❑ Stainless Steel 0 Other <br /> Grout Seal Depth c4 1;:>0 ft C' Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br /> ,11 Bentonite(20%solids) :1 Other <br /> Grout Placement Method 0 Pumped --i Free Fall ❑ Other U Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor V Other 0 i,,.1 N L' P— <br /> F, <br /> r, Concrete Pedestal CDimensions:Width ft Length ft Thick in ❑ Christy Box P. Stove Pipe <br /> PUMP 1*�7 Submersible[ Turbine r; Other HP Pump SetJ ft Standing Water Level O 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 COMPENSATION LAWS. <br /> MINI M HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE DATE <br /> Ul <br /> Sq <br /> N / C <br /> D Nq <br /> Fr <br /> F T <br /> DE ARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID#� <br /> Grout Inspection By 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 Received Checw Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> /Sg77 'T426,"' <br /> AS277 ' lZZ 1 -1$ <br /> � ��;�(Z �l�/� l� CJ� 7 � l � ��V'�I � �`�V_/� ✓` WELL/PUMP PERMIT <br />