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iz o, z3,1 <br /> WELUPUMP PERMITyib .9 so 0'0N J.69alllN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STDCKTDN CA 9 205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7637 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS lv 3 I j a`/���.r �. yt, c CITY/ZIP r ��LG ?'J m <br /> L <br /> CROSS STREET /�-�► l /APN "c' �a �` C7 <br /> PARCEL SI2E�- LAND USE APPLICATION# <br /> c�1�1 X19 Q �l�-s Zp— C <br /> OWNER NAME /r/IM/� t C E PHONE <br /> OWNER ADDRESS f . + CITY/STATE/ZIP <br /> CONTRACTOR A J��yQ�s D L LLoI l /.PHONE 7`7/ 4-✓ <br /> CONTRACTOR ADDRESS �� CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP p <br /> LICENSE %.ja'57 C-61 D-09 Other NUMBER:7j:. l�J EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ., Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name ontact ame or Phone um er <br /> TYPE OF WORK New Well i Replacement Well i Well Alteration/Modification i Other <br /> Monitoring Well(s) _ #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well i Out-Of-Service Well Renewal i 1 Cross-Connection Repair <br /> .k pew Pump 1 Pump Replacement Pump Repair 1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodKMud Rotary i i Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth3'10 ft Excavation — in diameter Open Bottom Xavel Pack/Gravel Size V4 in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 4CL in Thickness/Gauge/ASTM Sched'L00 Steel "10 Plastic IStainless Steel Other <br /> Grout Seal Depth /ou _ft Neat Cement(94 lb bag/5-10 gal water) Viand Cement ��,-1 sack mW7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method umped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller i Pump Contractor i Other <br /> i 1 Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP bmersible 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 /> MIINNI-MUUM 24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)/953-7697 <br /> SIGNED ��cS�S�"� TITLE DATE <br /> C <br /> olS <br /> n p. <br /> l.' Q <br /> r <br /> �U—jl 4 C O N <br /> PMA )m Er-:rN,1 I I A <br /> A T <br /> DEPARTMENT USE ONLY Tuht�(�•„�la'� <br /> Application Acceoted Ri%'�/ _--.__--.—__– ae Area l Employee ID# <br /> Grout Inspection By Date `� l7 Fj SPECIAL Well Permit <br /> Pump Inspection B ?�' Q� ate ❑ WAIVER Received <br /> Soil Boring insDe.t•rn p1 �nata Cnnctructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Arnount Date Permit/ Invoice# Well iD# <br /> Codes Info B Cash Remitted Service Request# <br /> li ZD i .SRpa��-121IN DON 0 <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4/30/12 — <br />