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WELUPUMP PERMIT <br /> SAN JOAt1UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> [ION-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS l I 'lIV �1 q 1n CITY2IP.�rO�l�c:f]Q� �cLodi 9K-2_q�) m <br /> D <br /> - v <br /> CROSS STREET A r I-A SJ 77TH YI APN PARCEL SIZE 3 �5� LAND USE APPLICATION# m <br /> D Ing- (,e ✓ Unr)U I (261 3Eq 1381 <br /> OWNER NAME ��c���1� �! ��'1/{1 QC� QL1 �1 J PHON C/ �J <br /> OWNER ADDRESS 1 l 'l L4� / I CITY/STATE/ZIP e_o, / �/A��7l �L/y� � <br /> CONTRACTOR aSLP 1t(j� r1 11j'n�_ 1/!C�• PHONE JI.L, 1! 2, C <br /> CONTRACTOR ADDRESS k l� A( �e-fs K ��. CITY/STATE/ZIP 1443 1 a J rm 57U J <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 [1 C-61 I D-09 U Other NUMBER / ' <br /> W2—Ci EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private G Irrigation/Agricultural ❑ Industrial i7 Water Quality Monitoring U Soil Sampling/Characterization <br /> P Public Water System <br /> If different from Owner: Water System Name -tact Name or Phone Number <br /> TYPE OF WORK 'Kew Well ll Replacement Well ❑ Well Alteration/Modification Cl Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pum r' Pump Replacement U Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methodyl Mud Rotary U Air Rotary ❑ Auger ❑ Cable Tool U Push Point ❑ Other <br /> Proposed Well Depthft Excavation 2 in diameter U Open Bottom Gravel Pack/Gravel Siz in diameter <br /> ❑ Conducto Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bent ite(20%solids) [1 Other <br /> Grout Placement Method umped -i Free Fall C Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box P Stove Pipe <br /> PUMP F: Submersible[; Turbine I] Other HP Pump Set It 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 COMPEI4 ION LAWS. <br /> MI HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209)953-7697 <br /> /�, 11 <br /> SIGNED lL <br /> _- �..7 TITLE 1 � �• DATE �7— <br /> "N <br /> el <br /> L <br /> O <br /> % <br /> C� <br /> s <br /> h <br /> I I HIE I <br /> t; <br /> Nlit� <br /> N IR <br /> H LH EARM N <br /> PA TMENT Uya <br /> LY <br /> Application Accepted By .;5& Date � Area Employee ID# <br /> Grout Inspection By v Date ❑ SPECIAL Well Permit <br /> Pump Inspection By ���ON 6A013 �� � Date �� (3a` l ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received he Amount Date PermiU Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> I S v lb 3s <br /> 'HD 43.06 WELL/PUMP PERMIT <br /> 4/30112 <br />