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WELUPUMP PERMIT r <br /> J.64W IIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> IrNON-REFUNDABLE PERMIT CALL(209)953-7637 FOR INSPECTIONS EXPIRES <br /> f1�YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 7�.� y�� CITY21P �� CIG v� m <br /> CROSS STREETLk �h <br /> y�/� A/PN "u�� � �/ PARCEL SIZEy3 LAND USE APPLICATION# �j ^� M <br /> OWNER NAME /1T/�IM/l L.G, i/ uOJL� PHONE -Z<t --S Z0- 2-5 l N <br /> OWNER ADDRESS i CITY/STATE/ZIP /� r <br /> CONTRACTOR a,,//�JJ S .4 l /.PHHOONE 33 Y`Z.7 L✓ <br /> CONTRACTOR ADDRESS ��—&--,4- CITY/STATE2IP "7/�_W4�' <br /> SUBCONTRACTOR ••ss�� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ad..Ia�57 Il C-61 Ii D-09 Other NUMBER37��C?S EXPIRATION DATE C-17 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE y,,<­Domestic/Private Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring f_i Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name ontact Name or Phone Number <br /> TYPE OF WORK %<New Well i Replacement Well i Well Alteration/Modification i Other <br /> Monitoring Well(s) #of wells i Soil Boring(s) _ #of borings 1 1 Geotechnical #of borings <br /> i Out-Of-Service Well I Out-Of-Service Well Renewal Cross-Connection Repair <br /> ;4*1ew Pump i Pump Replacement Pump Repair Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling MethodKMud Rotary I.] Air Rotary Auger Cable Tool Push PointI Other <br /> Proposed Well Depth3 ZX2 _ft Excavation in diameter Open Bottom Xavel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter C in Thickness/Gauge/ASTM Sched'L-`X3 I Steel y Plastic I Stainless Steel Other <br /> Grout Seal Depth_ 2a ft Neat Cement(94 Ib bag/5-10 gal water) Viand Cement � j)' sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method umped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By >46riller Pump Contractor Other <br /> Concrete Pedestal i Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP mersible Turbine Other HP Pump Set 2--7 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 /> MINI-MUM 24 YOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)/953-7697 <br /> SIGNED_±���C.S�W� � TITLE ©C.JI��i L�- DATEA [CID <br /> tb <br /> 5 <br /> IAJ <br /> 0 <br /> N1 09 <br /> r <br /> UI qO N <br /> 4H A LTI, <br /> DEPARTMENT USE ONLY TyI�nLY�1a'7 <br /> Aprlication Accepters By — yteb2ol i Area l Employee ID# <br /> Grout Inspection By Datel7 O r7 SPECIAL Well Permit <br /> Pump Inspection B ate 11 WAIVER Received <br /> Soil Boring InFW1, <br /> 'n�R Il�ata Constructed Well Depth ft <br /> COMMENTS,_ c <br /> p s - <br /> PE SC Received ! Amount Permit/ I <br /> Codes Info By Cash Remitted Date Service Request# Invoice# Well ID# <br /> lI yo t s2cO-7 W BON 13 I <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 - <br />