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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARIYENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES <br /> � '1nYEAR FROM DAT�EE ISSUED <br /> (q <br /> JOB ADDRESS • _ CITYZ )P L L !N g <br /> CROSSSTREET APN �'� �,. SIZE DOSE APPLICATIOU <br /> A <br /> OWNER NAME r, <br /> qR <br /> OWNERADDRESS CM1111TATIEMPPaaf <br /> CONTRACTOR 7 <br /> iCONTRACTOR ADDRESS CITYISTATEMP <br /> SUBCONTRACTOR P14ONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEMP <br /> / J <br /> LJDENSE VC-57 r-,C-61 -D-09 -1 Other NUMBER%/" � EXPIRATION DATE <br /> 15;/2,71 <br /> INFO TION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE DomesticfPrivate _7 Inigaaon/Agricultural D Industrial O Water Quality Monitoring D Soil Sampling/Charactedzation <br /> L Public Water System <br /> If diMerent I—On,. a.er em ame a oma or ne u r <br /> TYPE OF WORK IYNewWFql 'Replacement Well =Well Alterabon/Modification Other <br /> - <br /> r-Monitoring Well(s) *ofwells Soil Boring(s) wof bow .I Geotechnical 9 o bodngs <br /> Qut-Of-Service Well Out-Of-Service Well Renewal i,Cmss•Connection Repair <br /> New Pump 1 Pump Replacement C Pump Repair ,Raise Well Casing <br /> WELL CONSTRUCTIONS <br /> Drilling Method C Mud Rotary _Air Rotary _Auger It Cable Tool ❑Push P/oft Other <br /> Proposed Well Depth ..Nr"� ft Excavation_��in diameter =open Bottom -1 Gravel PadJGravel Size__in diameter <br /> Conductor Casing in diameter / Conductgr Casing Dep(t1� ft <br /> Well Casing Diameter "J <br /> In Thickness/GaugeJASTMSrhed l CSC' lee. <br /> I/P tic rt Stainless$/¢,a1 (i Other <br /> Grout Seal Depth_j_ ft ��Neat Cement(94/b bag15-10 gal water) ,/'Sand Cement �(i "/ sack mixl7 gal water <br /> Bentonite(2Q%solids) -7 Other <br /> Grout Placement Method um :!Free Fall C Other -Retardant/Accelerator(name) <br /> PEDESTAL Installed By VDfiller -Pump Contractor r; Other n '•� <br /> Co erete Pedestal nDimensions:Width ft Length R Thick in Christy Boz Stove Pipe ,`r�'�}��•1�'Iy <br /> PUMP SubmersibleU Turbine ^Other HP Pump Set ft Standing Water Level R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN I q <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE m, (( <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSA1101 L/1WS. <br /> MINtIUOUR ADVANCE NOTICE REQUIRED FOR <br /> NSPECTIONS-PLEASE CALL(209)9 3-769 <br /> TITLE DATE <br /> � I I <br /> LLI 11 <br /> I <br /> i <br /> - � A <br /> LET--- I 1 1 1 1 7TTTI I <br /> 1 <br /> DEPARTMENT USq ONLY r <br /> Application Accepted Bip Date I Area �I Employee IDSI�t� <br /> Grout Inspection gY Date- Y C SPECIAL Well Permit <br /> Pump Inspection By Date t, L' WAIVER Received <br /> Soil Boring Inspection By Date Constructed We pth ft <br /> COMMENTS <br /> S - r <br /> PE SC Reeawed C Amount Date Permit/ Invalee# We111Dt <br /> Codes Info B Cash Remitted ServireR uestfF <br /> o.- l .` 61 7 Ib cS1�D��(Od S fin! 0 13 <br /> 5o iS /7 a 7W no�Hml <br /> u• I <br /> EHD,saa _ _ _ <br /> �TlN1Y �J / 103/`0/ J �2 ///` WELL RU- PERMR <br />