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WELUPUMP PERMIT <br /> t'AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT A , CALL/209 953-7697 FOR INSPECTIONS <br /> INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 41 JOB ADDRESS ,V �./� ` +�(� CITY21P `�� <br /> CROSS STREET APN 25 1419-lip PARCEL SIZE LAND USE APPLICATION# 70 <br /> OWNER NAME PHONE y <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> f CONTRACTOR <br /> PHONE47-53 f'-1/7147!2� <br /> CONTRACTOR ADDRESS /00 13CITY/STATE/ZIP <br /> SUBCONTRACTOR \ J 2 7 y <br /> � � PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 1 C-61 I I D-09 1 Other NUMBER37/7 <br /> Wf'_ EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE :'Domestic/Private I i Irrigation/Agricultural 1 Industrial i Water Quality Monitoring 1 Soil Sampling/Characterization <br /> 1 Public Water System <br /> If different from Owner: ater ystem Name —fact Name or Phone Number <br /> TYPE OF WORK ew Well ><-Replacement Well 1 I Well Alteration/Modification I Other <br /> I Monitoring Well(s) #of wells I Soil Boring(s) #of borings I Geotechnical #of borings <br /> Out-Of-Service Well i i Out-Of-Service Well Renewal i Cross-Connection Repair <br /> -A;Wew Pump Pump Replacement i Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 1 Air Rotary I Auger Cable Tool Push Point i i Other <br /> Proposed Well Deptr _RQ ft Excavation t in diameter 1 Open Bottom Xravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel Mastic Stainlgss Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b bag/5-10 gal water) Sand Cement zo 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 xCbriller Pump Contractor Other - /1+ <br /> Concrete Pedestal Dimensions:Width 7ft Length > ft Thick = in Christy Box Stove Pipe <br /> PUMP u bmersible Turbine 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 /> GI IRREN_T AND ACTIVE WITH THE CALIFORINIA 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)953-7f�697/ <br /> SIGNED TITLE C J(AJ �'. DATE <br /> 1.4 <br /> i r — <br /> .12 <br /> Fr tit <br /> J <br /> J <br /> EP RTMENT USE INLY <br /> C // <br /> Application AccepteDate V Area Employee ID#r:9�2 o <br /> Grout inspertio Date lL h SPECIAL V1lsll Perrrtl# <br /> Pump Inspection By Date VvAiL'ER Received <br /> Soil Boring Inspection.By pate Constructed Well Depth ft <br /> COMMENTS1,U11JW b2 UaN14,21 14 StAUteg <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info_ B Cash Remitted Service Request# <br /> 3 b .°° �iP -75`� IN POO 3lo41 q <br /> u 3 W <br /> EHD 43-05 WELL/PLIMP PERMIT <br /> 4/30/12 <br />