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r ' <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN 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 /> L (7 �f� �,/ <br /> JOB ADDRESS ,7�Z c [`,ol.��} t`C• CITY21P�-S nt ��' <br /> CROSS STREET I�=C1 eta" W xY APN Z QHS` I � 2 PARCEL SIZE /6-103 LAND USE APaP�LI�CAATI/ONS#+ m <br /> OWNER NAME `�`)��5 JP r 13 tt u(f PHONE <br /> OWNER ADDRESS O2-" ���Z �--� �� CITY/STATE/ZIP ls1'Ca/_0-K- A, rJ G <br /> IYlct�e-1l�' 1`� ' yy <br /> CONTRACTOR (� 'P"( �1( +r�-9 PHONE�'lZ�" r `2- <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS L -7 t ICITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 57 `1 C-61 IJ D-09 11 Other NUMBER la ii JRA EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE U Domestic/Private rrigation/Agricultural ❑ Industrial Ci Water Quality Monitoring U Soil Sampling/Characterization <br /> H Public Water System <br /> If different from Owner: ater ystenn Name Contact Name or Phone Number <br /> TYPE OF WORK j'7�New Well I1 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well U Out-Of-Service Well Renewal El Cross-Connection Repair <br /> R New Pum r!. Pump Replacement U Pump Repair 11 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 11 Push Point ❑ Other <br /> Proposed Well Depth- Lft Excavation .2-0— in diameter ❑ Open Bottom l Gravel Pack/Gravel Size in diameter <br /> Ll Conductor Casing in diameter / Conductor Casing Depth / 1 ft <br /> Well Casing Diameter IZ in Thickness/Gauge/ASTM Sched-24!5;0 'J Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ,5'40 ft - Neat Cement(94 lb bag/5-10 gal wafer) >qand Cement I e,-:? sack mix/7 gal water <br /> r_I Bentonite(20%solids) '.1 Other <br /> Grout Placement Method L umped El Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By U Driller Allump Contractor U Other <br /> Concrete Pedestal F--'Dimensions:Width ft Length ft Thick in Christy Box 71 Stove Pipe <br /> PUMP F SubmersibleU 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR (INSPECTIONS- PLEASE CALL (209)953-7Q697r <br /> SIGNED TITLE [)--`(� DATE <br /> ra 7/4 <br /> f <br /> G <br /> tiIY <br /> At 1 <br /> ++i I I I I <br /> Ca t~ H <br /> EPARTMENT USE ONLY / <br /> Application Accepted By'A� Date I�J±�^7=) Area Employee ID# <br /> Grout Inspection By Date 2 T l ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> L-1 <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received eck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> 110 V l�2 �� a t� ►� 0( 9Dr <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4/30/12 <br />