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//t/ ' /Z 36 <br /> Gze`7 / Uo WELUPUMP PERMIT <br /> SAN JOAQUIN CdJNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT s CALL 209 953-7697 FOR INSPECTIONS EXPIRES 9 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /�/�� CITY/ZIP. Y `t �� m <br /> � D <br /> 0 <br /> CROSS STREET & APN JL)5 D _PARCEL SIZE/d/LAND USE APPLICATION# <br /> OWNER NAME { AC j� AV/ _ PHONE 61)7— `2-3y <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> r C� 7— <br /> CONTRACTOR �Il PHONE R E d 43 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP_�/ D�� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 6WS7 C-61 -i D-09 ❑ Other NUMBER <br /> ,� 7 J�_- EXPIRATION DATE_ <br /> GEOGRAPHICAL INFORMATION: Coordinates X— Y Township Range___ Section _ <br /> INTENDED USE Domestic/Private rrigation/Agricultural Industrial U Water Quality Monitoring U Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: aterystem Name Contact ame or one Number_ <br /> TYPE OF WORK ><ew Well i 1 Replacement Well Well Alteration/Modification I Other <br /> i Monitoring Well(s) #of wells Soil Boring(s) ___ n of borings i Geotechnical #of borings <br /> qut-Of-Service Well Out-Of-Service Well Renewal i i Cross-Connection Repair <br /> ew Pump Pump Replacement Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method—.Mud Rotary Air Rotary Auger C Cable Tool Push Point Other <br /> Proposed Well Depth-3___ft Excavation in diameter I Open Bottom ><ravel Pack/Gravel Size_ in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth _ It <br /> Well Casing Diameter 6-- in Thickness/Gauge/ASTM Schad Steel ,blastic 'I Stainle s Steel I Other_ <br /> Grout Seal Depth S C.� It i Neat Cement(94 Ib bag/5-10 gal water) �nd Cement sack rnix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method n Pumped 1 Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width_�ft Length ft Thick in Christy Box r I Stove Pipe <br /> PUMP :submersible Turbine Other HP Pump Set It 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 REGULA T iONS. I ALSO CERTIFY THAT L'Y 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 /> MINI UM 2 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED TITLE /9I.tf/`E�- DATE <br /> ofi <br /> i <br /> sl <br /> v <br /> p O <br /> N� UA i <br /> 1 21 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date r) Area Employee ID# "Sc eTz <br /> Grout Inspectiorg % Date ❑ SPECIAL Well Permit <br /> Pump Inspection By U Date ❑ WAIVER Received <br /> Soil Boring Inspection B Date Constructed Well Depth ft <br /> COMMENTS r <br /> ' `� a m ! (Lv �cr�e» 0 9P <br /> c <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By I <br /> 1, Remitted Service Request# <br /> a,3oL �� Q 2`I[, ` 1 <br /> P s 2 s 3 i2o o 733 0 t0 q15 <br /> I <br /> END 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />