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& . WELUPUMP PERMIT F ✓" <br />4-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 /> JOB ADDRESS lo # iters6&j kwe, CITY/ZIP If7o-C(nTo" CIP 952 /Sr <br /> CROSS STREET y/Ll1iJ 2 ` APN' f / 0 -1 PARCEL SIZE LA D USE APPLICATION# m <br /> �I/cn �/ � QN PHONE a�9- 7- <br /> 0 <br /> OWNER NAMEPH <br /> OWNER ADDRESS FA tte%S/OA4 TZC' CITY/STATE/ZIP Te"L) lily !25--215 <br /> CONTRACTOR 3�dYI �/�F/l/�/!� M[ �P/HONE <br /> /� <br /> CONTRACTOR ADDRESS �)( /� ;2-7 CITY/STATE/ZIP /�/TZ <br /> SUBCONTRACTOR PHONE2eW -r72. - .27!5-7 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE '(C-57 C-61 D-09 Other NUMBER 1,L1)_1_'7,0-7 EXPIRATION DATE T'" 3 / 4P <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water Name Contact Name or Phone Number ' ,- <br /> TYPE OF WORK �CNew Well i Replacement Well i Well Alteration/Modification Other <br /> Monitoring Well(s) _ #of wells i Soil Boring(s) #of borings Geotechnical #ofpborings <br /> Out-Of-Service Well i Out-Of-Service Well Renewal i Cross-Connection Repair /j,L <br /> New Pum Pum Replacement Pum Repair i Raise Well CasingSA/y 9 ?418 <br /> WELL CONSTRUCTION Ely, 1/V C <br /> Drilling Method VMud Rotary Air Rotary Auger Cable Tool Push Point Other NFALTHD NIyF�TANTy <br /> Proposed Well Depth_ ft Excavation 6 <br /> in diameter Open Bottom V Gravel Pack/Gravel Size MI. in dial ter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter c in Thickness/Gauge/ASTM Sched / Steel /11Plastic Stainless Steel Other <br /> Grout Seal Depth Ann ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cementsack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By A Driller 1 Pump Contractor i Other <br /> Concrete Pedestal i Dimensions:Width It Length ft Thick in i Christy Box i Stove Pipe <br /> PUMP Submersiblei Turbine 1 Other HP 1 1/2— Pump Set / ft Standing Water Level j' It <br /> I HEREBY CE14TIFY 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 COMPENSATION LAWS. <br /> MINIMU4 R ADVANCE N REQUIRED FORINSPECTIONS - PLEASE CALL(209)9953-7697 <br /> SIGNED F TITLE_Te1_- ��x� DATE <br /> e <br /> k-1 IV <br /> n <br /> v <br /> EPARTMENT USE ONLY <br /> Application Accepted By Date Area I %C Employee ID# <br /> Grout Inspection By f VUL Date _ ❑ SPECIAL Well Permit / <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Insp tion By Date Constructed Well Depth ft <br /> COMMENTS on- cc,, I S 0'4 c,wl I41%r)KI 11A 61 <br /> PE Sc Received C-fLecko Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> `I33� ITO a q 1 vr75r- <br /> UY OS a GZ 1ST /fitw b `d <br /> 3 I IyS 7 g <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4/30/12 <br />