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i041, Scan W <br /> 2-4F 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 /> --. . <br /> Ln <br /> JOB ADDRESS / �/s.J l+✓ '\ CITY21P e-15 -_6n1D <br /> CROSS STREET `ems l' <" APPNN/ —0 PARCEL SIZE2' �_LAND USE APPLICATION# �^ *� y <br /> OWNER NAME L�i'�// f— 4` 44, PHONE ' [�())�� (� V l� y <br /> OWNER ADDRESS ��/f I :r 7��Gy P�L /� CITY/STATE/ZIP <br /> CONTRACTOR A OL—A � �/Ike <br /> PHONE <br /> i CITY/STATE/ZIP ADDRESS <br /> 061's <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ---<-57-57 C-61 I D-09 I Other NUMBERc.,�`7 3c'(^ EXPIRATION DATE <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 System Name ontaa ame or hone Num er <br /> TYPE OF WORK' New Well Replacement Well i Well Alteration/Modification i Other <br /> I Monitoring Wells) #of wells i i Soil Boring(s) #of borings i Geotechnical If of borings <br /> ut-Of-Service Well Out-Of-Service Well Renewal i Cross-Connection Repair <br /> ew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethooxMud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth3-X, -) ft Excavation . 1 z in diameter Open Bottom 1 Gravel Pack/Gravel Size in diameter <br /> 1 Conducto asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 7 oc�, 1 Steel <Plastic I Stainless Steel 1 1 Other <br /> Grout Seal Depth_ „ ft Neat Cement(94 lb bag/5-10 gal water) �tSand Cement j✓� r3 sack mix/7 gal water <br /> Bentonite(20%solids) Other " <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By"<Driller I Pump Contractor i Other <br /> Concrete Pedestal Dimensions:Width ft Length It Thick in 1 1 Christy Box Stove Pipe <br /> PUMP submersibleTurbine Other HP r 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 /> JOAQU!N 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 2HOI�R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED �� TITLE 0 C11141— DATE 5 `� <br /> f <br /> L <br /> E <br /> OJ; <br /> Ilk I <br /> V., lit y <br /> ON 1 Ir <br /> v T <br /> FITT -TT-FF- )�7r4glitt ! 11111, 11' ri, 11, 111- 11111 <br /> I <br /> DEPARTMENT USE ONLY <br /> Application Accepted Date Area Employee ID# <br /> Grout Inspection By Date �� F I SPECIAL Well Permit <br /> Pump Inspectio '6 - Date A ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />