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//t,l; /r'Dv <br /> ,`�"17 �• rZ..� Zt'llhq1 Ran ��15/1� AV <br /> WELUPUMP PERMIT <br /> SAN.I0410IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT S CALL 20e9 953-7697 FOR INSPECTIONS (EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / V J r— N Ave— CITY/ZIP r^ <br /> D <br /> CROSS STREET A" J Lam' ..yam APN PARCEL SIZE C? LAND USE APPLICATION# Cf � <br /> OWNER NAME ��✓� ( /?/i4•t PHONE 'L <br /> OWNER ADDRESS �/�W Lo CITY/STATE/ZIP <br /> CONTRACTOR AJ7A r-742 `SS aU ,[O PHONE 79- J!�77-f' <br /> CONTRACTOR ADDRESS 00J -79 CITY/STATE/ZIP k/M07 QL <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> _,<C-57LICENSE tC-57 C-61 D-09 i i Other NUMBERS l773�i 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 ystem I ame Contact Name or one umber <br /> TYPE OF WORK -*4New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) I <br /> #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> .ice-New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method--Mud Rotary Air Rotary Auger i Cable Tool i Push Point Other <br /> Proposed Well Depth ft Excavation / in diameter Open Bottom ravel Pack/Gravel Size _in diameter <br /> Conductor Casing in diameter// Conductor Casing Depth ft <br /> Well Casing Diameter y in Thickness/Gauge/ASTM SchedL Z) i Steel Plastic i Stainless Steel i Other <br /> Grout Seal Depth ft i Neat Cement(94 Ib bag/5-10 gal water) §and Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method*40umped Free Fall Other 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By y-Miller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width +� It Length ft Thick in Christy Box Stove Pipe <br /> PUMP ;.!.Submersible Turbine Other HP Pump Set ft Standing Water Levelft <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 /> M I UM <br /> 4.7R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209)953-7697 <br /> SIGNED " TITLE_D � DATE 7-- <br /> AL <br /> 4 <br /> pa <br /> CD <br /> I TT <br /> Y <br /> FEWJCr- T1' <br /> I 'AFT ' <br /> YE4.r <br /> D F•. P T M E N T I I/S F C1 N I.. Y y <br /> Application Accepted By Date Area L Area 04 `I Employee ID#(a4 5,- — <br /> Grout Inspection Date l ❑ SPECIAL Well Permit <br /> Pump Inspection By / Date G ❑ WAIVER Received <br /> Soil Boring In tion By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info BY Cash Remitted Date Service Request# Invoice# Well ID# <br /> y36( st 123 Zq VJ�6031�`1u3 <br /> P 2 r3 -3-icy 5.2� 79 it7 0003 INO <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />