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WELUPUMP PERMIT <br /> J <br /> SAN JOAQL'.N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NOWREFUNDABLE PERMIT ,, CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Loh �bUNNe .D 3��J X15 20/0 m <br /> m <br /> JOB ADDRESS CITY/ZIP � D <br /> CROSS STREET At> APN -// Ci�P C PARCEL SIZE 'S-InC. LAND USE APPLICATION# z <br /> ,gyp W / �d /n <br /> OWNER NAME C.'TLy�W� !/1(V fV / PHONE Z b9 �//�,,� <br /> OWNER ADDRESS S77 ✓ t�Tin' CITY/STATE/ZIP l�i.weje srqu e. 4 <br /> CONTRACTOR � � > _ /5�f� S PHONE 1 032 3��-(P/ <br /> CONTRACTOR ADDRESS T 0 �x Lo-3p. <br /> o-j p"'�wrr CITY/STATE/ZIP ,65c J f !J tea& <br /> SUBCONTRACTOR fi A0\'55E,r Da-tU/�" PHONE 1 `� `�[�2 Gly <br /> SUBCONTRACTOR ADDRESS -1&01 b6lcu�D- pawt CITY/STATE/ZIP PtztO N y <br /> LICENSE C-57 C-61 D-09 Other NUMBER 3 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private Nrrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name C6ntacl Name or Phone Number <br /> TYPE OF WORK XNew Well Replacement Well i Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells i Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well i i Out-Of-Service Well Renewal i Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary ;Auger Cable Tool i Push Point Other <br /> Proposed Well Depth 105 ft Excavation Z(o in diameter 1 Open Bottom )LGravel Pack/Gravel Sizein diameter <br /> ta-Conductor Casing T.in diameter / Conductor Casing Depth p d`r ft <br /> Well Casing Diameter I(P in Thickness/Gauge/ASTM Sched -LSd Steel Plastic ){,Stainless Steel Other <br /> Grout Seal Depth 2 co ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method umoed Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By i Driller Pump Contractor Other <br /> XConcrete Pedestal Dimensions:Width__4t_ft Length_t _ft Thick 71L�_in Christy Box Stove Pipe <br /> PUMP Submersible)(Turbine Other HP U' Pump Set `fi C. ft Standing Water Level L ft <br /> 1 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 /> CUHRENT AND ACTIVE H THE CALIFOR A CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CO ENSATI <br /> MI WfV1WV )V CE TICE_ REQUIRED FOR IN PECTIONS- PLEASE CALL(209)953-769 /�- <br /> SIGNED TITLE W DATE 1'J <br /> f <br /> ke <br /> MAP— <br /> Aa <br /> r <br /> 4 <br /> 1 <br /> J <br /> y N / <br /> O p q <br /> DEPAR T MEN -1 USE ONLY <br /> Application Accepted By ate Area a �' Employee ID# <br /> Grout Inspection Date �7� < / ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ! WAIVER Received <br /> Soil Boring Inspection By Date Constructed``Well Depth ft <br /> COMMENTS 12,1 `��-w�� ' SISIl mi,,— 5Y� ` �L 6;?.M -.QOP� 64A 4 y--4 4=+41L_ac <br /> PE SC Received CheckW Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> 3&61 SO W1 37623 �`t( ''� 3 /S ,31 <br /> �1�5�>C t �pUO�l�ZgS <br /> LAI g:) o� 37� z3 S3 3 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />