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WELUPUMP PERMIT <br /> SA;+JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON OA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 3 i ' aJ D <br /> JOB ADDRESS ( CiTY21P✓ � m <br /> ES c,hLca —/30 — _ o <br /> CROSS STREET P 6 G�PARCEL SIZE LAND USE APPLICATION# m <br /> /ma y 1 <br /> OWNER NAME Zvi� PHONE �V � �,-+ <br /> IT <br /> OWNER ADDRESS X hl& CITY/STATE/ZIP <br /> CONTRACTOR s C/ PHONE / <br /> CONTRACTOR ADDRESS C ` U CITY/STATE/ZIP �Y Z <br /> - $ 7 _ <br /> SUBCONTRACTOR �ic VIA kez C, r PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP _ _ <br /> Llc9NS2 XC•57 C-61 L] D-09 IJ Other___ __— _ NUM13EEXPIRATION DATE- "15_ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> FENDED USE ><DomestiC/Private _1 Irrigation/Agricultural _1 Industrial i i Water Quality Monitoring L Soil Sampling/Characterization <br /> Public Water System--�- <br /> If different from Owner o er.yl rn ami ontagt tamQ ar ane .umer <br /> TYPj QF Wsg6,>0ew Well Replacement Well a Well Alteratlon/Modifloatlon Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical n of boringe <br /> ❑ Out-Of-Service Well n Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump Pump Replacement Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method*<�Mud Rotary ❑ Air Rotary Auger i Cable Tool ❑ Push Point I , Other <br /> Proposed Well Depth J 10 ft Excavation` in diameter I 1 Open Bottom j><Gravel Pack/Gravel Size in diameter <br /> 'I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameterin Thickness/Gauge/ASTM Sched _ i SteelPlastic Stainl Ste Other <br /> Grout Seat Depth/C20 ft I I Neat Cement(94 Ib bag/5-10 gal water) Ixand Cement ] sack mix/7 gal water <br /> Bentonite(20%solids) '' Other <br /> Grout Placement Metho Pumped Free Fall . Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller '-Amp Contrac or ❑ Other <br /> Concrete Pedestal Dimensions:Width ft Length=ft Thick _ in Christy Box Stove Pipe <br /> PUMP Submersible) 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI M 2 H/VRDVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209J) 953-7697 <br /> SIGNED TITLEDATE <br /> !_ D L_ L / <br /> 1 — <br /> _ <br /> _ - - <br /> r ) - <br /> EALTH DERAFTh I <br /> soon <br /> DEPARTMENT USE ONLY T4.a4t.4u <br /> Application Accepted B Date Area Ch Employee ID# <br /> Grout Inspect Date El SPECIAL Well Permit <br /> Pump Inspectio _ Date �� n WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS 0114 <br /> PE SC Received eck Amount Permit/ <br /> Codes Info B ash Remitted Date Service Request# Invoice# Well ID# <br /> ✓ 36b )$� lf'� g f 3 4 I — CO 70 9/ �QD3te�31 <br /> 3 R-O() 9 W 03133 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />