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WELUPUMP PERMIT <br /> C-9N JOAQUIN e;OUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT I CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �L'L/6 GJ�GLI lie l� CITY/ZIP c :p ZZ a m <br /> D <br /> 0 <br /> CROSS STREET if!�le' ile APN 12,7 /rd" 3 S PARCEL SIZE ?-LAND USE APPLICATION# <br /> Q �J- m <br /> OWNER NAME P GvC //��L/�L /�,Q? / W a PHONE 2e<7 / �Dr �97/ y <br /> S <br /> OWNER ADDRESS /• O "�CrI�j�ClL�`/ /�DL7 � -Al.. CITY/STATE2IP <br /> G'/Gil $22 7 <br /> CONTRACTOR 3� !/2%GCl/�Il� //7 �PHONE �(J`7 -7/lZs "2�75-7 <br /> CONTRACTOR ADDRESS Gam(/ �`L. I�OI!/� f/ CITY/STATE/ZIPIs GA �JZS Z <br /> J <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP Q 2 <br /> LICENSE )e C-57 C-61 D-09 i i Other NUMBER EXPIRATION DATE L/ - J/— rlQ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/PrivateIrrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water Syst m <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump A Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter V in Thickness/Gauge/ASTM Sched XSteel I Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-f0 gal water) I Sand Cement sack mixr/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall i Other i Retardant/Accelerator(name) <br /> f PEDESTAL Installed By Driller 1 Pump Contractor Other <br /> Concrete Pedestal 1 Dimensions:Width ft Length ft Thick in i Christy Box Stove Pipe <br /> PUMP Submersible i Turbine Other HP__::j_— Pump Set 2/L.� ft Standing Water Level /7(o 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 COMP SATION LAWS. <br /> MINI M 4 OUR A N TICE REQUIRED FOFJ-4NSPEFTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED TITLE I! CFO DATE -TE <br /> 41 <br /> e <br /> CI <br /> F <br /> NVIRONNT <br /> D E ARTMENT S UNTY <br /> O,(V L Y HEEgLT H DEPAMER� <br /> Application Accepted B Dat -S Area 'l Employee ID# <br /> Grout Inspection By Date Ll SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By DateIII)I p <br /> II r Constructed Well Depth ft <br /> COMMENTS PIn� <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codas Info By Cash 7 Remitted Service Request# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />