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WELUPUMP PERMIT <br /> •SAN JO1;QUIN 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 ADDRESS S'S ,6r 7 /V CITY/ZIPx W I�� `� O MCROSS STREET lax APN —q-PARCEL SIZE/ <br /> � � <br /> E/ LAND USE APPLICATION# j m <br /> OWNER NAME 643! CSD l3 PHONE -3-2--e7- �� <br /> OWNER ADDRESS o i CITY/STATE/ZIP <br /> CONTRACTOR -p� /�"�� e PHO E..> E— <br /> CONTRACTOR ADDRESS CITY/STATE2IP Lf'iG%L <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE �C-57 11 C-61 1 D-09 Other NUMBER) `-5 EXPIRATION DATE l? �7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE yg::�bomestic/Private I_ Irrigation/Agricultural !I Industrial -1 Water Quality Monitoring I Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name -------C—ontact Name or Phone Number r^� <br /> TYPE OF WORK , New Well >4-11eplacement Well I I Well Alteration/Modification 1 I Other l'� <br /> of borfn /� <br /> I Monitoring Well(s) If of wells I Soil Boring #of borings s) r It. Geotechnical�L/6a,A <br /> I Out-Of-Service Well 1 Out-Of-Service Well Renewal 1 Cross-Connection Repair 3 2016 <br /> ew Pump 1 1 Pump Replacement I Pump Repair 1 Raise Well Casing SAN <br /> DrillnLL C Metho cnoN N�q N���Onq�N��N <br /> Drilling d�Mud Rotary I Air Rotary I Auger 1 Cable Tool I Push Point _ Other � L <br /> Proposed Well Depth? 9, ft Excavation /'I- in diameter I I Open Bottom ravel Pack/Gravel Size in diamel�r <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 1C in Thickness/Gauge/ASTM Schede 1 Steel Mastic LI Stainl ss Steel I Other <br /> Grout Seal Depth �J u ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement 6 sack mix/7 gal water <br /> Bentonite(20%solids) I Other <br /> Grout Placement Method *cPumped I Free Fall 1 Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By >4Driller i Pump Contractor I Other <br /> I Concrete Pedestal 'Dimensions:Width ft Length ft Thick in I Christy Box i Stove Pipe <br /> PUMP ubmersiblel 1 Turbine I Other HP Z2 _ 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 HQUR ADVANCE.NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697/ <br /> SIGNED TITLE DATE Z?— 7 <br /> i nb <br /> ,r <br /> rV <br /> lo <br /> t` <br /> i <br /> DE ARTM ENT USE ONLY <br /> Application Accepted B , to 30 7o1 (2 Area Employee ID#6Z-0-Ora <br /> Grout Inspection -� bate �� ❑ SPECIAL Well Permit <br /> Pump Inspection y Date / ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTSOL ('r <br /> PE Sc Received Check Amount Date PermiU Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> 0 1 Sr,1-00.7s(05 30 7 <br /> �0 .0 S 9- Sly a 136 <br /> i <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4/30/12 <br />