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'Tv-N4uI, lull <br /> 11tiELUPUMP PERMIT <br /> AN JO'AOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> ~ <br /> NON-REFUNDABLE PERMIT CALL 209.)9�53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / C��1 L Y�'�f/`� CITY/ZIP 6101'1' `J� <br /> CROSS STREET PARCEL SIZE LAND USE APPLICATION# a <br /> OWNER NAME l� (�ti"-/ /� 1 d y y `? <br /> � PHONE y <br /> OWNER ADDRESS tJ�r� CITYISTATE/ZIP <br /> CONTRACTORtPHONE , --// -2 2- <br /> " <br /> CONTRACTOR ADDRESS /-120 (Sa I CITY/STATE/ZIP r �I f>.t&& <br /> SUBCONTRACTCR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE >43-57 I C-61 D-09 I Other NUMBER% /3d,5' EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE *Zomestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK -*<New Well ,><Meplacement Well Well Alteration/Modification 1 1 Other <br /> Monitoring Well(s) #of wells i Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well i Out-Of-Service Well Renewal Cross-Connection Repair <br /> ew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodP"'CMud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth o,---:) ft Excavation — .b in diameter i Open Bottom `Gravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter� in Thickness/Gauge/ASTM Sched2_00 Steel 'Plastic 1 Stainles��S+teel I Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5 10 gal water) Sand Cement /[1,. sack mixd7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Methotl>,<Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor I I Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in 1 Christy Box Stove Pipe <br /> PUMP Submersible Turbine 1 1 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 /> MINIMUM 24OU/RADVANCE NOTICE REQUIRED FORRj INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED � _ o/ '"�' TITLE DATE-2—, <br /> I 4k <br /> zi <br /> I <br /> Y <br /> o <br /> _Ir � <br /> - - Q <br /> Ir <br /> DEPARTMENT USE O LY <br /> Q 1. <br /> Application Accepted By Date 97/ Area Employee ID# <br /> Grout Inspection By Date CA ❑ SPECIAL Well Permit <br /> Pump Inspection By Date d o ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS ' <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 937 l(?0 X316 X111 712 /1(0 SIz U��S 3 3(� vV p603104h9 <br /> 3 l 3 K`' -712T#b S O0 33-7 OU <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4+30/12 <br />