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&' = �=�1- ��li�i�l Sian 5 Ilz�l'► � <br /> 6W- 2 WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NQN-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS .J �✓ �(� CITY/ZIP <br /> ,y D <br /> CROSS STREET � � APN� p PARCEL SIZE2'��LAND USE APPLICATION# <br /> OWNER NAME /r�/�/a+-'G� � �a/�JLK-�:•A-'l PHONE ,4f;)7/� 0 q Q <br /> OWNER ADDRESS ��/�Yr^� 7?�WF:rV p�LY�/ CITY/STATE/ZIP <br /> CONTRACTOR PHONE / �L <br /> CONTRACTOR ADDRESS �/� d�JK� CITY/STATE/ZIP 4 o✓�Ii *-L L <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE �C-57 C-61 D-09 Other NUMBER`�.3'� � ✓c!P EXPIRATION DATE L) <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private Irrigation/Agricultural ! Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water yslem Name ontact Name or Phone Number <br /> TYPE OF WORK New Well i Replacement Well -, Well Alteration/Modification i Other <br /> Monitoring Well(s) #of wells i Soil Boring(s) #of borings Geotechnical #of borings <br /> ut-Of-Service Well 1 Out-Of-Service Well Renewal 1 1 Cross-Connection Repair <br /> ew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methosl,�Mud Rotary i Air Rotary Auger i-! Cable Tool Push Point Other <br /> Proposed Well Depth aX) ft Excavation _�-7,__ in diameter 1 Open Bottom i Gravel Pack/Gravel Size in diameter <br /> Conducto asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter t in Thickness/Gauge/ASTM Sched Lo—_. Steel Plastic StainlessSteelOther <br /> Grout Seal Depth_/)ft Neat Cement(94 Ib bag/5-10 gal water) "eSand Cement f V� '3 sack mix/7 gal water <br /> Bentonite(20%solids) Other / <br /> Grout Placement Method i Pumped Free Fall i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor I Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP >4ubmersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOACUI'14 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� HOl}R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED TITLE tbJ - DATE <br /> 1 <br /> 01 <br /> aft <br /> 7T i <br /> :4 <br /> I <br /> JI � <br /> H <br /> t <br /> DEPARTMENT USE ONLY //�� ,/ <br /> Application Accepted Date Area a Employee ID# ` <br /> Grout Inspection B Date 11l SPECIAL Well Permit <br /> Pump Inspectio Date Ilk, ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> 444� 43 44, <br /> s �_6-16 0 0� �;-7 'goD 12 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />