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WELUPUMP P''iERMIT <br /> SAN JOA;IUIN r-IJUNTY t.NVIRONIdENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> N-REFUNDABLE PERMIT CALF 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS6 /0 CITY/ZIP 4.A <br /> D <br /> _ o <br /> CROSS STREET_ ?Fr�,jeZXAPN O[j�X100 PARCEL SIZE LAND USE APPLICATION# M <br /> S' 'J�'�' t i Gj y <br /> OWNER NAME PHONE <br /> OWNER ADDRESS /S 6144 CITY/STATE/ZIP <br /> CONTRACTOR A L—AC�fzm- L[G j fv� )) PHONE L LJ r j <br /> CONTRACTOR ADDRESS r/A V - "�/177V CITY/STATE/ZIP <br /> SUBCONTRACTOR AVA/! 6 II-a 1.W_1&41S �_ 3 <br /> PHONE Z7_ <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP- <br /> LICENSE or{C-57 i C-61 I D-09 f I Other NUMBERS L 1> EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ; Domestic/Private ><Irrigation/Agricultural 1 Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water ystem Name Contact ame or one umber <br /> TYPE OF WORK XNeW Well I Replacement Well 1 Well Alteration/Modification I Other <br /> I Monitoring Well(s) #of wells I Soil Boring(s) #of borings I i Geotechnical #of borings <br /> Out-Of-Service Well I Out-Of-Service Well Renewal I Cross-Connection Repair <br /> 'i.,--New 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 Depth733 _ft Excavation t in diameter Open Bottom X-,ravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 46 in Thickness/Gauge/ASTM Sched2 n i Steel >'lastic I Stainless Steel Other <br /> Grout Seal Depth �6'� ft Neat Cement(94 Ib bag/5-10 gal water) and Cement �V,-i sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method-Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By .Driller 1 Pump Contractor I Other , <br /> Concrete Pedestal 'Dimensions:Width V ft Length ft Thick in i Christy Box r i Stove Pipe <br /> PUMP >,eSubmersible, Turbine i I Other HP 7 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, S1 ATE 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 /> MINI �jM�24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209)9533-7697 <br /> SIGNED z �fiV'-'U _ _ TITLE VCYA-tL DATE [ 1 1 <br /> L <br /> 2 <br /> 1 <br /> 4 - <br /> � a <br /> DEP�A TMENT USE O LLY <br /> Application Accepted Date— � �v Areae - - Employee ID# �TtJ <br /> 7 ' <br /> Grout Inspectio Date / /G l ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date J Constructed Well Depth ft <br /> COMMENTS� f1 �G / �y �•`T�L ��/ Cii%/C/l <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Request# Invoice# Well ID# <br /> ( 3 cg� oul�u�l� zp0750I <br /> S. � o Le 10 lulR UO q o <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />