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WELUPUMP PERMIT <br /> .�i.N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSftg �' G ) CITY/ZIP S V���� `1 115 I m <br /> D <br /> CROSS STREET t.9 r_,14� APN £?� v� PARCEL SIZE 31•a�_LAND USE AAPP�PLICATIION#�'` M <br /> OWNER NAME J—ion �� r�.� �7(� �3/� PHONE C'� 0 <br /> OWNER ADDRESS a o n CITY/STATE/ZIP /l <br /> CONTRACTOR i-4 6"rs+� 1J/L,�1��IY l /PHONE ?11.3 <br /> CONTRACTOR ADDRESS r s/ Oc J 172 2 �i CITY/STATE/ZIP`� a06 IZ•10 CL <br /> SUBCONTRACTOR\ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE a<-.Q-57 IC-61 i D-09 n Other NUMBER � S-' EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE srpomestic/Private Irrigation/Agricultural Industrial a Water Quality Monitoring L Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: ater ystem Name Contact Name or Phone Number <br /> TYPE OF WORK 'QVew Well i l Replacement Well f I Well Alteration/Modification ❑ Other <br /> i Monitoring Well(s) #of wells i 1 Soil Boring(s) If of borings Geotechnical If of borings <br /> I Out-Of-Service Well L Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 'New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method''<4-Mud Rotary Air Rotary Auger ❑ Cable Tool Push Point Other <br /> Proposed Well Depth 3 0'_ ft Excavation -L in diameter Open Bottom ravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter A;�_ in Thickness/Gauge/ASTM Sched i Steel I<Iastic Stainles_sSt I I Other <br /> Grout Seal Depth_/`� ft i Neat Cement(94 Ib bag15-10 gal water) Xand Cement Vlj sack mix/7 gal water <br /> I Bentonite(20%solids) i Other <br /> Grout Placement Method Pumped I Free Fall Other i Retardant/Accelerator(name) <br /> PEDESTAL Installed By><-Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft ThicrilC in Christy Box Stove Pipe <br /> Lu-MP ;�,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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI I M 24 HO ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)95/3--7697/ <br /> SIGNED `. TITLE � DATE <br /> 9 <br /> Z <br /> Z <br /> —z <br /> oz <br /> • z <br /> DEPARTMENT U E 7NLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date -291 ❑ SPECIAL WBII Permit <br /> Pump Inspection Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well D th ft <br /> C=TS [ <br /> -PAWL/?,/ <br /> PE Sc Received Check#/ Amount Permit/Codes Info By mash Remitted Date Service Request# Invoice# Well ID# <br /> q,370 tSO /2339 300 )-►7-I( 5/t0074T)-3- VvVoo�toyoq <br /> D <br /> I <br /> EHD 43.06 t! WELL/PUMP PERMIT <br /> 4/30/12 <br />