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T,{ IOSCa0IM13110W <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 2/09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> LP <br /> JOB ADDRESS ! 0 ��� /`� X`� !/"� � CITY/ZIP <br /> Lr/� �[�/� �/� m <br /> D <br /> / v <br /> CROSS STREET l APNaH -M/� Y PARCEL SIZELAND USE APPLICATION# m <br /> Cn <br /> OWNER NAME OD CZ14-P PHONE 3 66 <br /> OWNER ADDRESS hir CITY/STATE/ZIP [/ <br /> CONTRACTOR ( ( Pass 0&11,Z/ PHONE 73T411- L2—S <br /> t r � <br /> CONTRACTOR ADDRESS n•7, CITY/STATE/ZIP g5 5 <br /> SUBCONTRACTOR f' �`L/'v'^ L✓ r�y PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE _—57 C-61 D-09 Other NUMBER .� ll� EXPIRATION DATE —17 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private rrigation/Agricultural Industrial Water Quality Monitoring i Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK<New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) n of borings Geotechnical n of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> '-c1Vew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Metho&ClMucl Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth_4C7 0 ft Excavation in diameter Open Bottom �Kravel Pack/Gravel Size in diameter <br /> Condur Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched� Steel Mastic Stainless Steel Other <br /> Grout Seal Depth--_"` ft Neat Cement(94 lb bag/5-10 gal water) 1>dand Cement 0r,?.-,I 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 ContractorOther <br /> Concrete Pedestal !/Dimensions:Width f ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP oe-'Zubmersible, Turbine i Other HP 1> 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 /> MINIMUM 24 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209))953-7697/ <br /> SIGNED TITLE Q(_Al - -J— DATE J — _/ 46 <br /> r t <br /> r <br /> S <br /> -x <br /> 'Al Din I <br /> liv G Ut <br /> -M V1 <br /> if <br /> HAT <br /> DEPARTMENT USE ONLY <br /> Application Accepted BDate Area Employee ID#692 <br /> Grout Inspection By Date ❑ SP IAL Well Permit <br /> Pump Inspection By Date _ ❑ WAIVER Received <br /> Soil Boring Inspection By Date nstruct d Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Request# Invoice# Well ID# <br /> d 5-6—W <br /> �' •da 5-6-'Ib sit OC�7 � <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />