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U <br /> _ WELUPUMP PERMIT __ VC <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 /> N <br /> JOB ADDRESS , 4 1y CITY/ZIP_ o <br /> CROSS STREET PN '' I J PARCEL SIZE r Q� LAND USE APPLICATION# m <br /> OWNER NAME, "v �/1 '- _ �—/��j — N <br /> �}-� PHONE i <br /> OWNER ADDRESS �F%/ '/�/ / CITY/STATE/ZIP <br /> CONTRACTOR /�/� PHONE <br /> CONTRACTOR ADDRESS _ ! � ��Z ����7a �G�J CCITY/STATE/ZIP _711711-4i <br /> SUBCONTRACTORS/���� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE OeL3 -57 Q-61 I D-09 1 Other NUMBER i` �l EXPIRATION DATE �-�1-� +• <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y _ Township _ Range Section <br /> INTENDED USE loomestic/Private 1 Irrigation/Agricultural EJ Industrial C; Water Quality Monitoring U Soil Sampling/Characterization <br /> 1 Public Water System <br /> If different from Owner: Water System Name contact Rame or Phone Number <br /> TYPE OF WORK -)(Replacement Well ❑ Well Alteration/Modification El Other <br /> (i Monitoring Well(s) #of wells ❑ Soil Boring(s) _ of borings C Geotechnical u of borings <br /> 11 Out-Of-Service Well LI Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump F1 Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Method <br /> lud Rotary f i Air Rotary E I Auger U Cable Tool U Push Point LL Other <br /> Proposed Well Depth ft Excavation OZ in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter <br /> .1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thi c ess/Gauge/ASTM Sched _t'L L� U Steel 01astic ❑ Stainless Steel 0 Other <br /> Grout Seal Depth Cl Neat Cement(94 lb bag/5-10 gal water) and Cement Apt-4f, sack mix/7 gal water <br /> I Bentonite(20%solids) El Other <br /> Grout Placement Method) Limped Free Fall : Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 'I Driller Pump Contractor Other <br /> Concrete Pedestal : Dimensions:Width ft Length ft Thick in Christy Box F' Stove Pipe <br /> PUMP ubmersible i 1 Turbine I Other HPPump 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 4WIPEVSATION LAWS. <br /> MI �71 <br /> U CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95 -76SIGNED � %� TITLE L' �� _. DATE 3� <br /> 1 <br /> 4f Li <br /> QKJ <br /> 44 <br /> f� <br /> 05 - <br /> 5 <br /> E <br /> C <br /> C `4 AQ <br /> Z c j <br /> PARTM ENT US ONLY <br /> Application Accepted B Date l // Area Employee ID# r�V <br /> Grout Inspection B V�� -aj�_ Date 0 �/ Ll SPECIAL Well Permit <br /> Pump Inspection By � � V�J� ��� Date � �2'L( -u0\N L WAIVER Received <br /> Soil Boring Inspection By _ Date Constructed Well Depth_ __. ft <br /> COMMENTS <br /> PE Sc Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B as Remitted Service Request# <br /> �kN,-7S17-2 <br /> 71 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />