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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.4420 <br /> NON-REFUNDABLE PERMIT Z( 2 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �S__ Vz 1 ".V Cm21P ��L/1�L 1-�L4 m <br /> CROSS STREET r APN�'�aU o PARCEL SIE LAND USE APPLICATION#� m <br /> `i H <br /> OWNER NAME V e+HONE l� i 2 <br /> OWNER ADDRESS 2 Z CRY/STATE/LP !7 <br /> CONTRACTOR "41,4^� ` v PHONE <br /> CONTRACTOR ADDRESS Z CrrYISTATE/ZIP Q4kl <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS �C(RY/STAT"E�/ZIP <br /> LICENSE kf <br /> 57 i._C-61 D-09 ! Other NUMBER ( /3 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private i Irrigabon/Agricuttural Industrial Water Quality Monitoring , Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. water SYSWM Name GontaCt Name or ne NUMbOr <br /> TYPE OF WORK New Well Replacement Well Well Aiteration/Modification Other <br /> Monitoring Wells) #of Walls -Sol!Boring(o) If of borings Goctechnical 1t of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise WeII Casin <br /> WELL CONSTRUCTION - <br /> Drilling Method Mud Rotary 'Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter ; Open Bottom - Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel "' Plastic Stainless Steel '"Other <br /> Grout Seal Depth it Neat Cement(94 Ib bag(5.10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method , Pumped 1 Free Fall I Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By XDriller " Pump Contractor Other <br /> - Concrete Pedestal;'Dimensions:Width ft Length It Thick in Christy Box Stove Pipe <br /> PUMP K Submersibles 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 /> 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 DVAN NQTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED 4 - TrIL-0�n �7-- DATE F1 <br /> 2017 <br /> WRI RE�E�vE - <br /> OENTAL HEALTH <br /> T/SERVIr-ES <br /> �N�Q RpNM <br /> NE!`t.'[N SEP <br /> lit--- <br /> EP RTMENT USE ONLY LL <br /> Application Accepted By 21 Date �! / Area Employee ID#��,�(�������y,,�L)W7 <br /> Grout Inspection By Date CI^� ❑ SPECIAL WeII Permit <br /> Pump Inspection By 'Date ii C� WAIVER Received <br /> Soil Boring Inspection By Date Z its cted Well Depth It <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request S <br /> i;;Z % <br /> EHD 43-08 WELL/PUMP PERMIT <br /> 4!30112 <br />