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/i'liv <br /> ` .,, 0 - " WELUPUMP PERMIT ZI' IN �C��1 ��15�1� AV <br /> JOA::i:iiV COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE <br /> 'P PERMIT CALL 209" 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 11 T <br /> O ADDRESS / S �� r� �`Iv V�• CITY21P �!�/���' / L� D <br /> CROSS STREET [ �—�' ..yam APN l / �\ PARCEL SIZE LAND USE APPLICATION# L/ <br /> OWNER NAME ���� ! 1�IJh�f PHONE <br /> OWNER ADDRESS S/�YV�CS CITY/STATE/ZIP FSf_,t 11 <br /> CONTRACTOR aalzs — ��-yti PHONE'S <br /> CONTRACTOR ADDRESS -lar CITY/STATE2IP �1A&W-41- <br /> SUBCONTRACTOR <br /> G�QL <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIIT�Y/STATE2IP <br /> LICENSE ytC 57 C-61 D-09 I Other NUMBER j l77 EXPIRATION DATE C-12 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE I Domestic/Private<rrigation/Agricultural I Industrial Water Quality Monitoring I Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: ater ysttem fie Contact Name or Phone Number <br /> TYPE OF WORK a41ew Well Replacement Well i Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> T=New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method�Mud Rotary I Air Rotary I Auger I I Cable Tool i Push Point I Other <br /> Proposed Well Depth 4L ft Excavation - / in diameter I Open Bottom ravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter// Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schell,Z Steel <Plastic I Stainless Steel i Other <br /> Grout Seal Depth&) ft Neat Cement(94 Ib bagl5-10 gal water) >&and Cement 1,21-3 sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method;yl_Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ,o&iller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length=ft Thick in Christy Box Stove Pipe <br /> PUMP ;.C.Submersible Turbine I 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 /> M I UM <br /> 470 R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED � TITLE (41k— DATE44 <br /> ITY <br /> J <br /> 2 <br /> 0401 10.11— <br /> Ty <br /> 'ar T <br /> T <br /> DFP TMEj4T 11SF ONI.. Y //-- <br /> /I to #t Q5"_�J <br /> Application Accepted By � Date Area Employee ID <br /> LS �� p y <br /> Grout Inspection Date l ❑ SPECIAL Well Permit <br /> Pump Inspection By Date n WAIVER Received <br /> Soil Boring Intion By Date Constructed Well Depth ft <br /> COMMENTSAI <br /> G ' <br /> PE SC Received Check#/ Amount PermiU <br /> Codes Info B Cash Remitted Date Service Request <br /> # Invoice# Well ID# <br /> /23.2q 3 16 5��� w�6u3�103 <br /> 3L) 5-L-1 23 2 �3 �' �.-3-►� 5►2�.�y ► 7 Doi NO <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4/30/12 <br />