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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY EWRONMENTAL 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 /> G (7L K N <br /> Joe ADDRESS 1 S U l -e I i 1 e c j� CnY/LP c M �G' ; S J 0 o <br /> CROSS STREET ' 1\\ C �. APN V 17 C Q 1 PARCEL SIZE q'�(' LAND USE APPLICATION# m <br /> OWNER NAME L; 0• 4 kMeIIs SQ HONE 5�3 �S-� G �,Cryt/)')iP� <br /> OWNER ADDRESS C ! 1�0 b� I fJ S iTyrTA1.Z1P trrllpL^l. 1 ! L '4] <br /> CONTRACTOR �LT� / � 1 f� Ol PHONE 3�✓C/ '27{7-I <br /> CONTRACTORADDRESS G 3 C ( I[,tyCITY/STATE/LP �%�, �.� CIS {✓ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRYISTATEIZIP <br /> LICENSE AC-57 'A-C-61 D-09 Other NUMBER�Ct938�� EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE ,ZCDomesticJPrivate _IrrigatiorVAgricuftlual Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If lifkrem from O—r W.1er system Nam contact Nam or Pbont NUmber <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification -2 Other <br /> Monitoring Well(s) #of wells - Soil Bonng(s) a of borings Geotechnical aotbodrWs <br /> Out-0f-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement C Pump Repair -Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)C Mud Rotary -Air Rotary Auger Cable Tool - Push Point Other_ <br /> Proposed Well Depth7CR Excavation 12 11 in diameter Open Bottom Gravel PadUGravel Size I�Q - in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter <br /> In Thidmess/Gauge/ASTM Schad I L Steel X Plastic Stainless Steel Other <br /> Grout Seal Depth /Q it Neat Cement(94 Ib bag/5-10 gal water) >TSand Cement `C 3 sack mix17 gal water <br /> Bentonite(20%solids) _Other <br /> Grout Placement Method .Pumped Free Fall Other -Retardant/Accelerator(name) <br /> PEDESTAL Installed By X Driller Pump Contractor Other <br /> Concrete Pedestal-Dimensions:Width Z If Length ft Thick—CL in -Christy Box Stove Pipe <br /> PUMP Submersible-Turbine -Other HP aj Pump Set ft Standing Water Level C 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. 1 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 /> MINI x(24 HOUR <br /> ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED " T T/ CiIZ� CTITLE\ C(' i C S I t C ti 1 T DATE <br /> r � <br /> W <br /> 5 <br /> L- <br /> �JI f PAY <br /> R V E QED <br /> '710A <br /> T?610» <br /> 4 pco, <br /> s L r H DEpq�I'LL <br /> Lo L <br /> DEPARTMENT USE !rONLY <br /> Application Accepted By 4Date ��W I Area I Employee ID# U)Vn� <br /> Grout Inspection By Vti Date t111,12.01t1 :1 SPECIAL Well Permit <br /> Pump Inspection By Date -1 WAIVER Received 7� <br /> Soil Boring Inspection By Date Constructed Weil Depth tet/ R <br /> COM N 1 r I a i r L r OX J Ac+.+r <br /> > C I <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By Cash Remitted Date Seryice Re uest# invoice# WeI11D# f ii tf l +ti , <br /> Ji-7 go <br /> e <br /> EHD 43-05 /+ WELL/PUMP PERMIT <br /> 4/30!12 <br /> Ll 3N 0 s 79 t0/,W,/n LJ P M3752b <br />