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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 /> JOB ADDRESS YY G� �a f 1 7�� <br /> CITY/ZIP <br /> 1 m <br /> ^� v �- <br /> CROSS STREETC 1/TL � APN PARCEL SIZE LAND USE APPLICATION# m <br /> N <br /> OWNER NAME L ! ) PHONE �� - -� <br /> OWNER ADDRESS / v i- 1 [//,Lin CITY/STATE/ZIP <br /> CONTRACTOR /!0 r\ Reil J91tZ Com// ��I v PHONE � 4172-S <br /> R <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP �✓� Qat[{ /`moi vpL$1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE <br /> /ZI'P <br /> LICENSE .�-57 C-61 r D-09 Other NUMBER 3 73� EXPIRATION DATE m— I <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private :�-.<rrigation/Agricultural I I Industrial Water Quality Monitoring i I Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name ontact Name or Phone Number <br /> TYPE OF WORK J4Qlew Well Replacement Well I Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells I Soil Boring(s) #of borings I Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> ,>,Zew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methodpw' A- ud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> ' <br /> Proposed Well Depth 410 ft Excavation � in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing A161 .in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedZ.d?"* Steel KPlastic Stainless Steel Other <br /> Grout Seal Depth 15;5.> ft Neat Cement(94 Ib bag/5-10 gal water) ; and Cement _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 Pump Contractor�� Other <br /> Concrete Pedestal Dimensions:Width--�ft Length ft Thick in I Christy Box Stove Pipe <br /> PUMP Submersible }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 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-77697 <br /> SIGNED � TITLE 044.""dh- DATE Iz- vL,- <br /> V rs - <br /> i <br /> �5 <br /> ;z - 1210 - C <br /> i n <br /> / Al I <br /> - <br /> 1 _ - <br /> 3t. - � c <br /> iNVIRA Et T <br /> - D <br /> Di*!EPARTMENT USE O LY 61 <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well D th <br /> t <br /> COMMENTS S KSW'A <br /> r k � <br /> ,� <br /> PE SC Received ec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> (D3 l�i�i 6xm 716 g 3 W PooN'n I <br /> 050 0 3 r- , ►2 ►g i 200 7 ! P O 397- <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4/30/12 <br />