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T,(lihal SO 511211 <br /> WELUPUMP PERMIT <br /> 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 1YEAR FROM DATE ISSUED <br /> JOB ADDRESS Y ` � `� /v �� tz'o CITY/ZIP [yC� lr/1�.� m <br /> D <br /> CROSS STREET _ J 114+= APN 7 PARCEL SIZE LAND USE APPLICATION# <br /> / " m <br /> OWNER NAME /� PHONE <br /> OWNER ADDRESS it�t� CITY/STATE/ZIP <br /> CONTRACTOR /4.4-4 /,t�3.S' D �1, PHONE 3sf�y 72.,5 <br /> CONTRACTOR ADDR_gpo' <br /> ' CITY/STATE/ZIP <br /> SUBCONTRACTOR �rgz//_q <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE57 C-61 D-09 Other NUMBER � a�3 & EXPIRATION DATE 6-17 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private rrigation/Agricultural I Industrial i Water Quality Monitoring ri Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name ontact Name or Phone Number <br /> TYPE OF WORK -<N@W Well I Replacement Well i Well Alteration/Modification i I Other <br /> I Monitoring Well(s) #of wells I Soil Boring(s) #of borings I Geotechnical #of borings <br /> I Out-Of-Service Well I Out-Of-Service Well Renewal I Cross-Connection Repair <br /> JtK1Vew Pump ! Pump Replacement Pump Repair I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,<rMud Rotary I Air Rotary i Auger Cable Tool Push Point Other <br /> Proposed Well Depth�_It Excavation - I:Y in diameter Open Bottom °Gravel Pack/Gravel Size in diameter <br /> Conduclgr Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched P— Steel el�Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Viand Cement0O��.d� sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ' riller Pump Contractor�j Other <br /> Concrete Pedestal ' Dimensions:Width—�ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP ac=ubmersible Turbine Other HP Pump Set ft 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 COMPENSATION LAWS. <br /> MINIMUP 24 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-77'697 <br /> SIGNED TITLE / DATEy _� <br /> 1 <br /> }rpj. i <br /> H _qT <br /> DEPARTMENT USE ONLY <br /> Application Accepted B; Date '� � Area IL Employee ID# <br /> Grout Inspection By Date 11SP IAL Well Permit <br /> Pump Inspection By Date F.1 WAIVER Received <br /> Soil Boring Inspection By Date nstruct d Well Depth ft <br /> COMMENTS G 1-7 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> If% <br /> 1?0 <br /> �' 6z - oa <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />