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,,,�tt ' WELUPUMP PERMIT <br /> AN JVAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697FORINSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / V�7 -7 0 �Ci�� 5,-6,Lc f�AL• CITY21P fn <br /> CROSS STREET/A"+� 1 APN_��l!/ Q,�}�D� PARCEL SIZE ✓ LAND USE APPLICATION# <br /> OWNER NAME ��V�� j f7(�/Lf `7 V� (� G/ N <br /> PHONE <br /> OWNER ADDRESS /[ ` � CITY/STATE/ZIP <br /> (� <br /> CONTRACTOR' �- ozz aarz,4/-.-/t- ,r PHOON�E'3--SS / r ?. 2-ig <br /> CONTRACTOR ADDRESS / J I3� 1 p CITY/STATE21PZ Z'a/' ) a4%2 <br /> SUBCONTRACTCR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE >43-57 I C-61 I ' D-09 i Other NUMBER 3 J 73i v� EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE )CDomestic/Private Irrigation/Agricultural I Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Num er <br /> TYPE OF WORK -*CNew Well ,'<*placement Well Well Alteration/Modification Other_ <br /> Monitoring Well(s) #of wells i Soil Boring(s) #of borings i Geotechnical If of borings <br /> Out-Of-Service Well IOut-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 7 __ in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_(j_ in Thickness/Gauge/ASTM Sched2_00 . Steel Plastic Stainles.5 Steel Other <br /> Grout Seal Depth �� ft Neat Cement(94 Ib bag/5-10 gal water) ,Sand Cement , sack mix/7 gal water <br /> Bentonite(20%solids) I Other <br /> Grout Placement Methofl>,<Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal iDimensions:Width ft Length ft Thick in i Christy Box I Stove Pipe <br /> PUMP Submersible Turbine Other HP 7 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 /> MINIMUM 24 OUR DVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(20-9))953-7697 <br /> SIGNED ��� TITLE �i f3/`Q>` DATE7—ZJ _ <br /> v <br /> r � <br /> c <br /> Li <br /> I <br /> 1 <br /> ?A4V <br /> - - Q <br /> L I <br /> DEPARTMENT USE O LY <br /> / `. <br /> Application Accepted By' Date Area Employee ID# <br /> Grout Inspection BYM�L Date B ❑ SPECIAL Well Permit <br /> Pump Inspection By J13 Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Cons ructed Well Depth ft <br /> COMMENTS r <br /> .4441 P <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> 937 /90 1316 "`I 7/2$/1(o SRO(y79 3 3(v wh603&44 9 <br /> 3 t 3 3 1-712,9)11(9 S �D 3"3 7 OV1,90 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4!30/12 <br />