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i4/ ; /"'v 5W-1 10-;LZ;— (b t75v-� <br /> .Jt A)�Ii.✓:z* WELUPUMP PERMIT <br /> SAN JOAOUIN COUNT'ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST H,AZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> hJGIt! i 4-FUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ? <br /> ` `` `` M �f� <br /> JOB ADDRESS N. �` ��V� CITYRIP �G/L WL + �(/`� m <br /> O <br /> CROSS STREET11 APN U PARCEL SIZE J LAND USE APPLICATION# a <br /> Cn <br /> OWNER NAME``l 4t *50 4/,/' �A� PHONE r ; N <br /> � S,J <br /> OWNER ADDRESS f CITY/STATE/ZIP <br /> CONTRACTOR 004�/ r�� 0A/'?y//LPHONE 22) <br /> CONTRACTOR ADDRESS /�� L 79 CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C<-57 C-61 D-09 Other NUMBER{� x731?r /`EXPIRATION DATE C —/;7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE '+Domestic/Private Irrigation/Agricultural 1' Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: ater ystem Name Contact Name or Phone um er <br /> TYPE OF WORK lew Well n Replacement Well 0 Well Alteration/Modification i Other <br /> ❑ Monitoring Well(s) #of wells i Soil Boring(s) of borings i Geotechnical of borings <br /> �❑,/O��ut-Of-Service Well i Out-Of-Service Well Renewal i Cross-Connection Repair <br /> ,.1'�1VeW Pump Pump Replacement i Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method^Aud Rotary 1 Air Rotary I Auger Cable Tool Push Point Other <br /> Proposed Well Depth-3'Y'— ft Excavation _11- . in diameter Open Bottom <Qravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_C_ in Thickness/Gauge/ASTM Sched ZZZO Steel XPlastic ❑ Stainless Steel � Other <br /> Grout Seal Depth 1C)'0 ft Neat Cement(94 Ib vag/5-10 gal water) Sand Cement eQe_7 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 IPump Contract9r, Other <br /> I Concrete Pedestal Dimensions:Width ft Length 69 ft Thick in Christy Box i Stove Pipe <br /> PUMP jd.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 ;S <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�HHOR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-769/7 <br /> SIGNED ��l�j'� TITLE DATE <br /> 1 <br /> v <br /> N At M A <br /> [I! I I - IN <br /> DE ARTMENT USE N L Y <br /> Application Accepted a Date Area Employee ID#; <br /> Grout Inspection y Date I PECIAL Well Permit <br /> Pump Inspection By J Date 0 n WAIVER Received <br /> Soil Borin nspection By r Date I Constructed Well Depth ft <br /> COMMENTS titA Mv6q L./ ~ti lac J``�f'kti-'h <br /> Ailkant C 60144 K,,4 <br /> PE SC Received heck#/ Amount Permit/Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> sIZOD7(Pb 2 VNF0o3u"21to <br /> 10 25 d 0 0U 3 W Od S <br /> t °° 0 P5 1 ►2 (logz <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />