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Z{• <br /> WELUPLIMP PERMIT <br /> J <br /> SAN JOAQU N COUNTY ENVIRONMENTAL HEAL rH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PER T ACALL 209 953-:'697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> A3 IJ K►A��'� 2� <br /> CITY/ZIP 7�lG ` � � <br /> JOB ADDRESS �� m <br /> C.� D <br /> CROSS STREET `�J /, APN_�J �/ PARCEL SIZE LAND USE APPLICATION# a <br /> OWNER NAME ? QnL /t�7�. �YI3?� PHONE.�J r <br /> OWNER ADDRESS a�N1 CITY/STATE/ZIP <br /> CONTRACTOR � n.� ol PHONE <br /> CONTRACTOR ADDRESS /(J 07� f CITY/STATE/ZIP `��✓� L��+ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE .�-57 C-61 I D-09 I i Other NUMBER 37 73?-P EXPIRATION DATE o �� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private rigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact ame or Phone Number <br /> TYPE OF WORK New Well i Replacement Well Well Alteration/Modification i Other <br /> I Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal i i Cross-Connection Repair <br /> _ ew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ' Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation f�_ in diameter Open Bottom ravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter I in Thickness/Gauge/ASTM Sched Z--X> i Steel )<Plastic i Stainl7 Steel Other <br /> Grout Seal Depth- s3L L:-C ft Neat Cement(94 Ib bag/5-10 gal water) y�Sand Cement /J.- sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method,*-Bumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By yI i Pump Contractor i I Other <br /> I Concrete Pedestal !Dimensions:Width===&t Length ft Thick in i Christy Box I I Stove Pipe <br /> PUMP ,YLSubmersible Turbine I 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 /> MIfYIIJU JJ� O R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED "` TITLE �l�`�� DATE '7 Ig III (� <br /> i <br /> LA <br /> NI <br /> Z <br /> a� <br /> z <br /> o� <br /> Z <br /> ILL <br /> An <br /> Lot- <br /> DERTMENT USE ONLY <br /> Application.Accepted By - Date Area ` Employee ID# <br /> Grout Inspectio ate l ElSPECIAL Well Permit <br /> Pump Inspection By I Date ID ❑ WAIVER Received <br /> Soii Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> 13 yFvv 5j 8 I NJ�oo3c��1y 1 <br /> s3ff 7 g S1Zb0-72 D 13 <br /> .J <br /> EHD 43-06 WELL/PUMP PERM!? <br /> 413012 <br />