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WELUPUMP PERMIT <br /> t'AN JOAQ61N 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 /> 2_ X13 1 �q+'V1 , �° / <br /> JOB ADDRESS � —li CITY/ZIP ` JM ^J` <br /> D <br /> 0 <br /> CROSS STREET APN /gD'!If PARCEL SIZE LAND USE APPLICATION# <br /> m <br /> PHONE <br /> t OWNER NAME 1?1 m <br /> /� J <br /> OWNER ADDRESS �j,,�� CITY/STATE/ZIP <br /> CONTRACTOR � p �/7GJG1!�—a C� (Plyl-2 PHONE 53 • L L 2� <br /> �l CONTRACTOR ADDRESS / Q •J - <br /> CITY/STATE/ZIP <br /> SUBCONTRACTOR ��f= PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 1 C-61 I D-09 I Other NUMBER 13V We_ EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE %-Domestic/Private 1-1 Irrigation/Agricultural r Industrial I Water Quality Monitoring I Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water ystem Name Contacl Name or Phone Number <br /> TYPE OF WORK ew Well ,>cc eplacement Well i I Well Alteration/Modification _I Other <br /> I Monitoring Well(s) #of wells I Soil Boring(s) #of borings i-1 Geotechnical #of borings <br /> 1 Out-Of-Service Well i i Out-Of-Service Well Renewal I Cross-Connection Repair <br /> - New Pum -1 Pump Replacement I Pump Repair r, Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodMud Rotary Air Rotary i Auger I I Cable Tool I Push Point I 1 Other <br /> Proposed Well Deptl1_7 30 ft Excavation in diameter 1 Open Bottom Xravel Pack/Gravel Size in diameter <br /> I i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Z_7c) 1 1 Steel >LPlastic I Stainlgss Steel i i Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) and Cement �+� �� sack mix/7 gal water <br /> I Bentonite(20%solids) I Other <br /> Grout Placement Method '<pumped 1 Free Fall I Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By -1<briller 1 1 Pump Contractor I Other _-2 /+ <br /> I Concrete Pedestal ('Dimensions:Width ft Length ft Thick in i Christy Box 1 Stove Pipe <br /> PUMP b bmersibleI 1 Turbine I Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CER IFY 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 nCTWE .e.ITH THE CALIFORTNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI" 24 H UR DVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-769/7✓ <br /> SIGNED TITLE C1J/ 4`_ DATE <br /> c.� <br /> 01 <br /> J <br /> 1 1 <br /> EcP RTMENT USE INLY <br /> Application Accepte A ate Area Employee ID#r:;;rq�lta <br /> Grout inspertinn- Date lU ❑ SPE=CIAL Well Permit <br /> Pump rspection By Date FJ WAIVERReceived <br /> Soil Boring Inspection.By Date Constructed Well Depth ft <br /> COMMENTS ` itE-' j elt11Z <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info_ By Cash Remitted Service Request# <br /> 3 b .°° 5 WPOO Mi`A <br /> 0 3 G7 SS 3 <br /> EHD 43-05 WELL/PLIMP PERMIT <br /> 4/30/12 <br />