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WELUPUMP'PERMIT <br /> SAN JOAQUW 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 11YYEAR FROM DATE ISSUED <br /> JOB ADDRESS //0 0 � C�5�l � aL� CITY/ZIP J GGrG� /a D <br /> CROSS STREET 4�'O`!,It APN PARCEL SIZE`LAND USE APPLICATION# �6s. m <br /> &I <br /> , / R ^ m <br /> OWNER NAME IM C/�& r + PHONE5X'-` G0-- 7_7 Z y <br /> OWNER ADDRESSS�'N✓/L��" CITY/STATE/ZIP <br /> CONTRACTOR A`LI` 10 P I 19� j_,y /I PHONE 3 I 7'7 <br /> Q t <br /> CONTRACTOR ADDRESS / O O&A -7(? CITY/STATE/ZIPIr <br /> �C/ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE l:-e-57 C-61 D-09 Other NUMBER 3'7`?3c?j- EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X_ Y — Township _ Range Section__ <br /> INTENDED USE _'<omestic/Private Irrigation/Agricultural ❑ Industrial Water Quality Monitoring i Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone um r _ <br /> TYPE OF WORK New Welleplacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical If of borings <br /> Out-Of-Service Well i_i Out-Of-Service Well Renewal Cross-Connection Repair <br /> ,XNew Pump Pump Replacement I Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method>d4AuclRotary Air Rotary Auger 1 Cable Tool i Push Point i i Other <br /> Proposed Well Depth S 430 ft Excavation �_ in diameter i Open Bottom XGravel Pack/Gravel Size in diameter <br /> i Conductor Casing_ in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-6 in Thickness/Gauge/ASTM Sched i-30 Steel Xlastic ' Stainl qs/j Steel i Other <br /> Grout Seal Depth__ft i Neat Cement(94 Ib bag/5-10 gal water) Sand Cement �Vi _ sack mix17 gal water <br /> I I Bentonite(20%solids) I I Other <br /> Grout Placement Method Wmped 11 Free Fall I i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By NjeDriller n Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box r1 Stove Pipe <br /> PUMP ubmersible Turbine Other HP 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 /> MINIM M 24 HOUADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Ir)(4JA A�- DATE <br /> t t <br /> �CCJJ f CIA <br /> �I - <br /> jr <br /> -IF Ell V <br /> L <br /> O pINIINT <br /> TY <br /> ME <br /> L_ _ b . <br /> DEPARTMENT USE ONLY ��,1 <br /> Application Accepted B Date r Area I _ Employee ID# C-'-ScL5 <br /> Grout Inspection By Date T Ll SPECIAL Well Permit <br /> Pump Inspection B Date ❑ WAIVER Received <br /> Soil Boring Insp ction By Date Constructed Well Dept ft <br /> COMME TS W i <br /> PE SC Receivedheck#/' Amount Permit/ <br /> � - Date Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> #/Z'-{)- C,- <br /> U� 3 �, , 06 Z-20� W O W-12 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />