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' WELUPUMP PERMIT <br /> SAN 50AGUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,JOB ADDRESS LSl L- � `v _- CITY/ZIP O 9-53" m <br /> D <br /> v <br /> CROSS STREET �1�kV� 1�-"�� APN Obb PARCEL SIZEF r. LAND USE APPLICATION# m <br /> Qp <br /> __ J j <br /> OWNER NAME DA.lt'G A vwk raw h 011'1 (� (_ A I t� 'PHONE_S-1 3- 142-1 ----- � <br /> OWNER ADDRESS 1 _ Ack >^- CITY/STATE21Pa �_�Q_- <br /> CONTRACTOR II 6'e-ffil k zzk(-• - TTT PHONE572-2-7 112-9 <br /> �CONTRACTOR ADDRESS l q A IS CITY/STATE/ZIP M6je-5 11 C) / <br /> SUBCONTRACTOR _._. PHONE <br /> SUBCONTRACTOR ADDRESS _ _ CITY/STATE/ZIP--. <br /> LICENSE C-57 '1 C-61 D-0911 Other NUMBER_�� EXPIRATION DATE-V-30 - / ? <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range _ Section <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural 1-1 Industrial J Water Quality Monitoring a Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: ate- r Systems intact Name or Phone Nu--m e>f r <br /> TYPE OF WORK )(New Well I I Replacement Well ❑ Well Alteration/Modification r 1 Other <br /> Monitoring Well(s) _ #of wells ❑ Soil Boring(s) __ a of borings Geotechnical n of borings <br /> ❑ Out-Of-Service Well C1 Out-Of-Service Well Renewal Li Cross-Connection Repair <br /> I 1 New Pum r Pump Replacement ❑ Pump Repair I I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method (Mud Rotary I; Air Rotary I1 Auger Li Cable Tool I I Push Point ❑ Other <br /> Proposed Well Depth P ft Excavation 2 in diameter Open Bottom Gravel Pack/Gravel Siz in diameter <br /> 1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 10 in Thickness/Gauge/ASTM Sched 2-00--- 1 Steel XPlastic [I Stainless Steel Other_ <br /> Grout Seal Depths X20 ft -] Neat Cement(94 Ib bagl5-10 gal water) ❑ Sand Cement_ sack m;x/7 gal water <br /> Ix Bentonite(20%solids) :I Other <br /> Grout Placement Metho umped i_1 Free Fall Other I, Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller Pump Contractor ❑ Other <br /> n Concrete Pedestal -Dimensions:Width ft Length ft Thick in ❑ Christy Box n Stove Pipe <br /> PUMP I- SubmersibleG 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 1,141 ACCORDANCE Wi T H SAN <br /> JOAflUIN i.0U1:T1` 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 MHOUR ADVANCE NOTICE REQUIRE OR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TI7tE �� �T DATE 6- /r <br /> 1 <br /> �• r <br /> F- <br /> J <br /> EPARTMENT U E ONLY <br /> Application Accepted By /� _ Date�� 1 Area Employee ID#� <br /> Grout Inspection By �J�lrr ��i— Date U//2, g' ❑ SPECIAL Well Permit <br /> Pump Inspection By _ Date C] WAIVER Received <br /> Soil Boring I`gspectiorr)By I flat r"Onst 3roted W II Depth LC%�_.. ft <br /> COMMENTS // \ i =6 C �, lwi_ {V, r� .' v ���? -------....----- <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> , <br /> b <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />