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t <br /> WELUPUMP PERMIT <br /> *SAN JOAQUIN VDUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT <br /> f�p { CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> IA 1i1�� V '\ to <br /> 11/ � <br /> JOB ADDRESS UI' 1 m <br /> CITYl21P�1� � � �W �_— o <br /> CROSS STREET 1 i 1 y "� APN L� - ` ` v PARCEL SIZE 1 LAND USE APPLICATION# m <br /> cn <br /> OWNER NAME Y— `I S I I' �L' ` I ) L PHONE_ ( ,n N <br /> d�1i — 1I V (11/1/ I W �I <br /> OWNER ADDRESS W I'l IP';M _ CITY/STATE/ZIP /S C{��I / od /�7�t� <br /> CONTRACTOR 1v � III VIrII1 I� � I PHONE C5)LI — i`1 <br /> CONTRACTOR ADDRESS I I CI ft o oM/ I __.. CITY/STATE/ZIP to LU I . Iq <br /> SUBCONTRACTOR IV f\ PHONE <br /> SUBCONTRACTOR ADDRESS CI <br /> T <br /> Y/STATE/ZIP <br /> LICENSE 57 '] C-61 1 D-09 [1 Other NUMBER U 22' EXPIRATION DATE <br /> GEOGRAPHICAL INFO ATION: Coordinates X Y Township l�—' Range _ Section IFI <br /> INTENDED USE Domestic/Private [ Irrigation/Agricultural U Industrial I:i Water Quality Monitoring U Soil Sampling/Characterization <br /> I 1 Public Water System <br /> "If different from Owner: Water System Name ontact ame or Phone Number <br /> TYPE OF WORK "ew Well Replacement Well ❑ Well Alteration/Modification U Other <br /> Monitoring Well(s)--- #of wells ❑ Soil Boring(s) #of borings _ Geotechnical #of borings <br /> P Out-Of-Service Well U Out-Of-Service Well Renewal U Cross-Connection Repair <br /> i' New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodMud ) l otta�y i5 Air Rotary Auger �tLi Cable Tool I Push Point Other <br /> /te <br /> Proposed Well Depth V ft Excavation /1- in diameter Open Bottom I-. Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing ft <br /> asing Depth <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched �� ' 1 Steel I,, L Iastic C Stainless Steel � Other <br /> Grout Seal Depth�ly v ft Neat Cement(94 1b bag/5-10 gal water) C Sand Cement sack mix/7 gal water <br /> I.Aentonite(20%solids) I Other _ <br /> Grout Placement Method vrPumped :I Free Fall Other r Retardant/Accelerator(name) <br /> PEDESTAL Installed By �] Driller '7 Pump Contractor ] Other <br /> r' Concrete Pedestal Dimensions:Width ft Length ft Thick in Fj Christy Box ^ Stove Pipe <br /> PUMP r Submersibler Turbine I! Other HP Pump Set ft Standing Water Level It <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 REOUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENS ION LAWS. <br /> MINIMUMHW�,VNCE �N IC .REGlUIRED FO NS EICTIONS- PLEASE CALL (209) 953-7697 <br /> SIGNED _ // / TITLE I DATE <br /> IPF <br /> f <br /> U; IVII <br /> 1 ^ SL <br /> Ar <br /> R M N <br /> T I i D Pi R <br /> \Z I Ilk1 <br /> 4� v <br /> D E PARTMENTp USE ONLY <br /> Application Accepted By Date 0 1 Area Employee ID# <br /> Grout Inspection By Date r ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By ___..._...... Date _ Constructed Well Depth ft <br /> COMMENTS ' ' -biz <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> I+ ,'U � L+20 &- tI i2 <br /> `l 57 '8 <br /> EHD 43-06 WELL PUMP PERMIT <br /> 4/30/12 <br />