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1C <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN• OUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> c <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS _ V �' ! L� CITY/ZIP 4 �- m <br /> CROSS STREET 4s� 1//CJ�� APN _PARCEL SIZE LAND USE AP/PLICATION# m <br /> OWNER NAME ` C PHONE` -2 <br /> OWNER ADDRESS U i- /�� 5 `� CIITTY/STAA�TE/ZIP �/ y <br /> CONTRACTOR ��7V � ��e� �I_L C�� /fes c�/. (�(//^�/W PHONE 1_ V_ <br /> '; Lj <br /> CONTRACTOR ADDRESS G + / 6 CITY/STATE/ZIP A/Val <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ><C-57 C-61 D-09 f i Other NUMBER°tJ ?3 Rf EXPIRATION DATE �S, <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE i Domestic/Private irrigation/Agricultural ij Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK •mew Well I Replacement Well ❑ Well Alteration/Modification i Other <br /> Monitoring Well(s) #of wells I Soil Boring(s) a of borings i Geotechnical a of borings <br /> Out-Of-Service Well IOut-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> :.­s Iew Pump Pump Replacement i Pump Repair ❑ Raise Well Casing _ <br /> WELL CONSTRUCTION <br /> Drilling Method,--,'-'Mud Rotary ❑ Air Rotary Auger ri Cable Tool i Push Point I Other <br /> Proposed Well Depth...3410 It Excavation /A in diameter LOpen Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing�.in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schede X-` Steel KPlastic Stainless Steel 1 Other <br /> Grout Seal Depth !5;o ft Neat Cement(94 Ib bag/5-10 gal water) ,'Sand Cement 1121 sack mix/7 gal water <br /> Bentonite(20%solids) 1 Other <br /> Grout Placement Method>dumped ! Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By >jDriller Pump Contractor�� Other <br /> Concrete Pedestal Dimensions:Width--Iz ft Length ft Thick in i Christy Box Stove Pipe <br /> PUMP Submersible Aurbine Other HP .3 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 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 /> MINIMUM 24 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209))953-7697 <br /> SIGNED TITLE �l tIJ� 4> DATE <br /> r^ <br /> -AO Ata <br /> ISA OAd <br /> (O — — <br /> � //S� - <br /> i n <br /> I - <br /> I _ - <br /> L - CAt 111 I'm 1W Q iff <br /> _N1 11ROR0 T <br /> D - <br /> 5* <br /> DEPARTMENT USE O LY (.� �� <br /> Application Accepted By Date Area l Employee ID# <br /> Grout Inspection Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date El WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Als &130 NA wiK ,rca ✓ <br /> 7 ct A 2 <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B "La�FI� Remitted Service Re uest# <br /> � l a�(D3 ° �� I S;eI� 7!6 g 3 W FOO N 251 <br /> 03 li ,B i 200 7 ! P 0392-b <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />