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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 /> _ Ln <br /> JOB ADDRESS 32— f �� <br /> CITY/ZIP <br /> CROSS STREET PN_ PARCEL SIZE ( � LAND USE APPLICATION# a <br /> m <br /> OWNER NAME ` `/� �/LJ /f/ _ PHONE <br /> cn <br /> OWNER ADDRESS 'i CITY/STATE/ZIP <br /> CONTRACTOR PHONE Z -J <br /> CONTRACTOR ADDRESS / 3 1-7�� CITY/STATE/ZIP ��L/ L <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE >C:r_-57 C-61 D-09 Other NUMBER ') EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_- Range Section_ <br /> INTENDED USE Domestic/Privaterigation/Agricultural ❑ Industria QuaUlnitoring Soil Sampling/Characterization <br /> D Public Water System rt n <br /> If different from Owner: yste5 m Name t ne u er <br /> TYPE OF WORK >gew Well Replacement Well ❑ Well Alteration/ 1 I o � {qtr <br /> Monitoring Well(s) _ _ #of wells ❑ Soil Boring(st"t( mdf re #of borings <br /> `�O,ut-Of-Service Well ❑ Out-Of-Servic Wee ene i�fl� t�Ir�Ft��crtp <br /> �'w Pum Pum Replacement I' Pum Repair�y ��V1 si <br /> WELL CONSTRUCTION �f ,Ik/ls'r)1 <br /> Drilling Method--f Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth a ft Excavation / in diameter Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel 314Plastic ❑ Stainless Steel Other <br /> Grout Seal Depth So ft Neat Cement(94 Ib bag/5-10 gal water) and Cement � sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method w_'Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width:3-'-ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP ubmersible Turbine 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 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 UM 4 H R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br /> SIGNED TITLE /'�+�J DATE1_�/' <br /> air •" <br /> Aw <br /> 1� <br /> Ps li'.�i -Lt i L <br /> 1L Lf Fi L. 1. <br /> DEPARTMENT USE ONLY <br /> Application Accepted By - _ !� Date_ Z k'[ r Area �� Employee ID# <br /> —( <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date-_- ❑ WAIVER Received <br /> Soil Boring Inspection By Date <br /> Construnted►We/ll De h L✓ �O�J ft <br /> L4 <br /> l�/_0 — G <br /> -COMMENTS -� = ' Damp, <br /> — --- <br /> PE SC Received Check Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By s Remitted Service Request If <br /> 3�r. aaG 9f,67 9 3 <br /> CSC, Z X53 2G RCr'7 Lc, <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />