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WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.9420 <br /> NON-REFUNDABLE PLEERMiT n\ CALL(2,09)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATEISSUED <br /> JOB ADDRESS Crry/AP n 'J n <br /> CROSS STREET ,.�� ,�� <br /> AP //C�JV ii n PARCEL SIE Zl•O iD USE APPLICATION# <br /> 1 CCll (� /� /'�/� a <br /> OWNER NAME �'' _Im fir/ SI 'b�q PHONE, '^�I DQ (Q(•�J( y <br /> OWNER ADDRESS S P,Wt C�_/ CITY/STATFIZIP V l� <br /> CONTRACTOR PHONE/T f? <br /> CONTRACTOR ADDRESS CfTY/STATFIZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATE/ZIP J/�� <br /> LICENSE 0 G-57 C 61 n D-09 0 Other NUMBER adL61 EXPIRATION DATE O �--��ioL <br /> GEOORAPNCAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private P Irrigation/Agrlwiturel ❑Industrial n Water Quality Monitoring I Soil SamplIng/Characterizatlon <br /> 11 Public Water System <br /> It(l!rrerent fmm Owner. water System Name eme or ne Numuer <br /> TYPE OF WORK r New Well rl Replacement Well n Well Alteratlon/Modificagon n Other <br /> C Monitoring Wells) #of welts 0 Sol[Boring(s) 4 of borinp C Geotechnical s of borings <br /> G Out-0fSerWCa Well 0 Out-WService Well Renewal /l Cross-Connection Repair <br /> New Pum CI Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CousTRucnON <br /> Drilling Method rt Mud Rotary 1;Air Rotary Ci Auger U Cable Tool L1 Push Point U Other <br /> Proposed Well Depth ft Excavation In diameter la Open Bottom 0 Gravel Pack/Gravel Size In diameter <br /> C Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_In Thickness/Gauga/ASTM Schad -,Steel C Plastic C.Stainless Steel I:1 Other <br /> Grout Seal Depth ft G Neat Cement(94/b begr5 10 gal water) !l Sand Cement sack m/X/T gal water <br /> r,Bentonite(20%solids) n Other <br /> Grout Placement Method n Pumped c Free Fall Il Other iJ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller G Pump Contractor : Other <br /> C,Concrete Pedestal rlDlmensions:Wldth ft Length ft Thick in C Christy Box 0 Stove Pipe rl <br /> PUMP r!Submersible!.I Turbine n Other HP r PUMP Set ft Standing Water Level It CENE� <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAS <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE Ill r 1 0 2019 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WiTH ALL <br /> WORKERS COMPENSATION LAWS. SAN J <br /> M IMU 24 HO ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209 9 3-7797 E QV►N�pUN <br /> SIGNED TITLE DATE fiFi QNMI C n' <br /> �EPgRTMENT <br /> L <br /> I 1Y 11,0 <br /> PA TMENT USE 9NLY <br /> Application Accepted By Date t� � Area Employee ID# I <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By < 1e 0 Date 2`� ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> OA WP004ol <br /> EHD 43-M <br /> 4/30112 WELL/PUMP PERMIT <br />