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/N' ? /� <br /> WEL UPUMP PERMIT <br /> SAN JOAOUI N COUNTY ENVIRONMENTAL HEAL rH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PEVT7,�_ AC�tALL�(2y0`9)95n3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> i60-A�V,! I`� CITY/ZIP � m <br /> JOB ADDRESS > a m <br /> C� D <br /> / J v <br /> CROSS STREET JJ APN. �I- _PARCEL SIZE ` LAND USE APPLICATION If <br /> OWNER NAME 2 j�L /�� �Y�L, YJ� PHONI�..�J r R N <br /> OWNER ADDRESS J/�N�n� CITY/STATE/ZIP <br /> CONTRACTOR �/J�n.Q / Z ° PHONE LAS /L� �✓� <br /> CONTRACTOR ADDRESS /(7 !� ' 17c�? CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP r <br /> LICENSE x-57 C-61 D-09 L Other NUMBER.3-2 ;7'3F > EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private i:llrigation/Agricultural Industrial Water Quality Monitoring F Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: ater ystem Name Contact Name or Phone umber <br /> TYPE OF WORK `<New Well Replacement Well Well Alteration/Modification Other <br /> I Monitoring Well(s) #of wells I Soil Boring(s) #of borings i Geotechnical #of borings <br /> Out-Of-Service Well 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 Cable Tool Push Point Other <br /> Proposed Well Depth_ ft Excavation in diameter i Open Bottom i ravel Pack/Gravel Size�_in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter6 in Thickness/Gauge/ASTM Schad 7__X2 Steel ><Plastic StainlesJSteel Other <br /> Grout Seal Depth S�Lc%C ft Neat Cement(94 Ib bag/5 10 gal water) ym Sand Cement !y.-3 sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method>LQumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By -griller i Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width 1 A Length ft Thick in Christy Box Stove Pipe <br /> PUMP >46ubmersiblei Turbine ' Other HP Pump Set It 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 HOA'�R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED LTITLE � DATE <br /> I <br /> LU <br /> Z <br /> Q� <br /> Z <br /> 2 <br /> > <br /> ZLU <br /> ir <br /> DEPARTMENT USE ONLY <br /> Application.Accepted By – Date Area L Employee ID# <br /> Grout Inspectio y o - ate l 11 SPECIAL Well Permit <br /> Pump Inspection By I Date 0 ❑ WAIVER Received <br /> Soii Boring Inspection By Date Constructed Well Depth it <br /> COMMENTS <br /> PE SC ReceivedL13 <br /> heck#/ Amount Permit/Codes Info BCash Remitted Date Service Request# Invoice# Well ID# <br /> ► 1:bo 7�g1�10 y �5151 -1 7 5 IIVs�o�>a 2 13 <br /> EHD 43-06 WELL/PUMP PEHMi <br /> 4/30!12 <br />