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WELUPUMP PERMIT <br /> $%`1 j-0AQV.N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CAL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> H Ln <br /> JOB ADDRESS V r, CITY/ZIP S��C�/� m <br /> D <br /> p� — 030 —fly etND o <br /> CROSS STREET �"/LCA' APN '.l9`I PARCEL SIZE J�^+ LAND USE APPLICATION# � <br /> m <br /> OWNER NAME <br /> no l�, Lil�tri4i G�/�LP PHONE V r 7 2 Y N <br /> OWNER ADDRESS :V' `D �A /� /� CICITY/STATE/ZIP <br /> CONTRACTOR A i—A ��,�"f� r//CjZ�1 1'+-1 PHONE <br /> CONTRACTOR ADDRESS P) i�✓�O /� CITY/STATE/ZIP_ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -%,,C-57 C-61 D-09 Other NUMBER-3:2 J EXPIRATION DATE_ <br /> GEOGRAPHICAL INFORMATION: Coordinates X_ Y Township Range Section <br /> INTENDED USE Domestic/Private ><Irrigation/Agricultural Industrial Water Quality Monitoring i_I Soil Sampling/Characterization <br /> i Public Water System <br /> �If'different from Owner: Water System Name ontadName or one um er <br /> TYPE OF WORK ' ,Iew Well 1 ' Replacement Well i Well Alteration/Modification 1-1 Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Qut-Of-Service Well i Out-Of-Service Well Renewal 1 Cross-Connection Repair <br /> '�<ew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method-7'�Iud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> i <br /> Proposed Well Depth ft Excavation S in diameter Open Bottom j(ravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_/_Qin Thickness/Gauge/ASTM Sched I ?SD Steel Plastic Stainless Steel Other <br /> Grout Seal Depth O ft I Neat Cement(94 Ib bag/5-10 gal water) XSand Cement �01 �? sack min/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped n Free Fall i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump ContractorlOther <br /> , <br /> Concrete Pedestal I Dimensions:Width z ft Length ft Thick in i Christy Box Stove Pipe <br /> PUMP Seubmersible 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 /> JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND PULES AND REGULATIONS. 1 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 /> Mill! UR #tVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209))953-7697 <br /> SIGNED �� ti TITLE C) 1 DATE [ly-J <br /> 1 <br /> Ifu f" <br /> 60 <br /> 1, <br /> 0 <br /> I J <br /> L-1010 <br /> Q <br /> 1 p A <br /> 1(� <br /> a <br /> DEPARTMENT USC C N L Y -- <br /> Application Accepted By o _ Date 1 Area ` Employee ID#�`�SIE' <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump!nspection B Date G _ ❑ WAIVER Received <br /> Soil Boring Insp ction By Date Constructed Well Depth ft <br /> COMMS T �Z l+ 5 c /! /SrtiJ" <br /> 6Gf++ <br /> PE SC Received Check#/ Amount PermiU ' <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well tD# <br /> yj 7 rev /I/L'T /a 452 f 3y/." jI s�to73 <br /> 06 /�`f32-- S °' 1 2 rZ��3-7 132 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />