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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 t CALL <br /> /A��209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS O "f`' L ""� CITY/ZIP �� �� 2� m <br /> D <br /> 1 <br /> Cl( r <br /> CROSS STREET 0 O APN U3L Vq D PARCEL$IZEU=� LAND USE APPLICATION# C� <br /> IV <br /> OWNER NAME �l/�-Ci I,"&M PHONE <br /> OWNER ADDRESS 9/"n a CITY/STATE/ZIP <br /> ell,CONTRACTOR S PHONE <br /> �Z 7 2S <br /> CONTRACTOR ADDRESS � CITY/STATE/ZIP(/L/ 9'gq IE <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS _ _ CIT <br /> 'Y <br /> 7/STATE/ZIP _ <br /> LICENSE 4-57 1 i C-61 I I D-09 I I Other NUMBERS?� EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates Y Township_ RangeSection____ <br /> INTENDED USE omestic/Private Irrigation/Agricultural I Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name ontactName or Phone Number <br /> TYPE OF WORK New Well >4eplacement Well i Well Alteration/Modification Other <br /> Monitoring Wells) #of wells i Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well i Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump Pump Replacement ' Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method<Mud Rotary Air Rotary Auger I i Cable Tool Push Point 1 Other <br /> Proposed Well Depth2— ft Excavationin'�— in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched-L,30 _ 1 Steel Mastic I Stainless Steel CI Other <br /> Grout Seal Depth_/�_ft Neat Cement(94 lb bag/5-10 gal water) >&and Cement �� sack mW7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method a Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Di<Driller 1 Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width t Length ft Thick in I_I Christy Box Stove Pipe <br /> PUMP >49ubmersible I Turbine 1 1 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 /> MI 17 24 O!rANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED ��'// TITLE DATE la —� _ <br /> 4 n <br /> G —1 55, <br /> it <br /> UP <br /> L <br /> l <br /> I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date lot -2( Area 1>4 Employee ID# Lj <br /> Grout Inspection B Date r_so ,/6 0 SPECIAL Well Permit <br /> Pump Inspection By Date �L��l (� ❑ WAIVER Received <br /> Soil Boring Insp@ tion By _ Date / Constructed Well Depth ft <br /> COMMENTS` 6( Lc:� ;6— al'r_' 1S~) LA w <br /> PE SC Received '-,_ChecjaV Amount Permit/ <br /> Codes Info B ash Remitted, Date Service Request# Invoice# Well ID# <br /> Ir o0 333 WP00 (03V-? <br /> 1.1 31?v a> Z; 67koo 73335 wroo 3 <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4/30/12 <br />