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' WELUPUMP PERMIT <br /> SAN JOAGUIN 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 { I ,Vr K, CITY21P AC4 Yt,") / `� m <br /> m <br /> ` n _ 0 0 <br /> CROSS STREET /J�[� �/` APN 013/ PARCEL SIZE LAND USE APPLICATION# <br /> U) <br /> OWNER NAME I (1 JL � 'tel PHONE <br /> OWNER ADDRESS l CITY/STATE/ZIP C� <br /> CONTRACTOR C�I� � /i.l 1 L t PHONES <br /> CONTRACTOR ADDRESS AO (2-oZ J-7 CITY/STATE/ZIP,�� c,-(-,6-?3- <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> r <br /> LICENSE >4-57 1 1 C-61 I D-09 I Other NUMBEZ: ' ` EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE „Domestic/Private Xrrigatlon/Agricultural I Industrial i Water Quality Monitoring _ Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK. ,+4ew Well Replacement Well i Well Alteration/Modification I Other <br /> L I Monitoring Well(s) #of wells 1 Soil Boring(s) #of borings i Geotechnical #of borings <br /> Li Out-Of-Service Well I Out-Of-Service Well Renewal tion Repair <br /> .kblew Pump Pump Replacement Pump Repair Raise Well Cas <br /> WELL CONSTRUCTION <br /> Drilling Method"* f ud Rotary I 1 Air Rotary Auger 116<le Tool I I Pus Point 1 Other <br /> Proposed Well Depth_ , Excavation in diameter O n Bottom ravel acWGravel Size in diameter <br /> Conduc Casing in diameter / Condu for Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 1 Steel astic i I S inless Steel i. Other <br /> Grout Seal Depth 7 ft I I Neat Cement(94 Ib bag/5 10 1 water) d Ceme ��ci:_ sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Methodi<Pumped Free Fall 6t Retardant/Accelerator(name) <br /> PEDESTAL Installed By n Driller r1 Pump Co actor Other <br /> 'i Concrete Pedestal Dimensio s:Widt Length ft Thick in Christy Box Stove Pipe <br /> PUMP submersible- Turbine Ot r H Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS AP LICATIO AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAW , AND R ES A REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNI CONTRA R STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI M 24 HOU ANCE NO Cl REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697—/ <br /> SIGNED v" n ` <br /> �l�LE�I tJ.L�L— DATE� <br /> L <br /> zo <br /> T <br /> SA <br /> E vl ,N C <br /> H 'Le )A A <br /> 'EA Ir <br /> T � <br /> 77--t- <br /> DEPARTMENT U S E O N L Y 11 , <br /> Application Accepted By Date tt) Area 0Employee ID# 5L-6k•�-C� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring I spection ByDate Constructed Well Depth ft <br /> COMMENTS c f I <br /> PE Sc Received Amount Date Permit Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> �"v 0) ,� RM-7 <br /> 5 y" G OQ <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />