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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 1 YEAR FROM DATE ISSUED <br /> � m <br /> -tCITY/ZIPA"X JOB ADDRESS � <br /> D <br /> /_11s4 <br /> �1 f 0 <br /> CROSS STREET LiC_.�fF��/G//�{' APN TU / f 1 s4 ()6 PARCEL SIZE I �J LAND USE APPLICATION# n <br /> OWNER NAME ( 71/VL}� �' T L�k PHONE�� 71f 7- 4W37 y <br /> OWNER ADDRESS �C/ 5/ ✓&57�� 41 CITY/STATE21P �C �/�//�/� ell �LJ v�C/ <br /> CONTRACTOR /i?s /' g _�/LL LL�/'Jl� i PHON 2-74-17-7 <br /> CONTRACTOR ADDRESS (�1(J `-C �L��XT�! CITY/STATE/ZIP N"7 4 Y�f//I/�.SCil/ <br /> �f <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP Q 2 <br /> LICENSE *C-57 i , C-61 I D-09 I Other <br /> NUMBER �.y EXPIRATION DATE lJ <br /> GEOGRAPHICAL INFORMATION: Coordinates X;0'61 tJiJ jC� _ Y��U7� G//23/— Township Range Section <br /> INTENDED USE 1 Domestic/Private )(Irrigation/Agricultural ❑ Industrial Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Name Contact Name or hone umber <br /> TYPE OF WORK )( New Well I Replacement Well ❑ Well Alteration/Modification I Other <br /> i Monitoring Well(s) #of wells ❑ Soil Boring(s) If of borings I Geotechnical11#of borings <br /> I Out-Of-Service Well ❑ Out-Of-Service Well Renewal i Cross-Connection Repair �tl[V 18 2018 <br /> New Pump [_I Pump Replacement ❑ Pump Repair Raise Well Casing SAN O <br /> WELL CONSTRUCTION ENT IRON""I.; i rY <br /> F1Drilling Method W'Mud Rotary Air Rotary I Auger [ H <br /> Cable Tool Push Point I I Other H DE EN <br /> L <br /> i <br /> Proposed Well Depth�G ft Excavation iZ /y in diameter Open Bottom ;( Gravel Pack/Gravel Size in diameter <br /> L_j Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-(e- in Thickness/Gauge/ASTM Sched IDIE 2 i u Steel 4 Plastic IStainless Steel C Other <br /> Grout Seal Depth I ft i Neat Cement(941b bag/5-10 gal water) A Sand Cement /f,- sack mix17 gal water <br /> I Bentonite(20%solids) i Other <br /> Grout Placement Method td Pumped 1 Free Fall I 1 Other F1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor i Other <br /> Concrete Pedestal (Dimensions:Width±-2:1_ft Length ft Thick (v in I Christy Box I Stove Pipe <br /> PUMP XSubmersible i Turbine I Other 9-,6R62 HP Pump Set ft Standing Water Level Z21- 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 COMPEN N LAWS. <br /> MINI UUR AD EN ICE REQUIRED FOR SPECT( NS- PLEASE CALL(209) 53-7p97 <br /> SIGNED 17V TITLE DATE <br /> FFFI <br /> EP RTMENT USE 9NLY <br /> Application Accepted By� Date f' Area Employee ID# <br /> Grout Inspection By Date to ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check# Amount Date Permit/ Invoice# Well ID# <br /> Codes 4nfo B Remitted Service Request# <br /> CQ/to v -I�1� weQo�1(��,3i <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4/30/12 <br />