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.. Tvv�k 5 cu-I to-x5-16 M— <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUN"rY 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 /> JOB ADDRESS � S 1" CITY/ZIP��+� ' � m <br /> CROSS STREET APN d/PARCEL SIZE_`— - LAND USE APPLICATION# <br /> OWNER NAME 2—X AP IZIIAPPHONE S��Z'��v 3 �? <br /> OWNER ADDRESS 04 CITY/STATE/ZIP <br /> CONTRACTOR lex (;A ss tt /"p PHONE 33q-4/72__r <br /> CONTRACTOR ADDRESS <br /> �r�d 6 17 z7 CITY/STATE/ZIP <br /> SUBCONTRACTOR •��J PHONE /ti- -'Zw <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE t,<U-57 ❑ C-61 F1 D-09 ❑ Other NUMBER 7�*3?J EXPIRATION DATE C-17 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE .Domestic/Private ! Irrigation/Agricultural Industrial Water Quality Monitoring 1 1 Soil Sampling/Characterization <br /> 1 Public Water System <br /> If different from Owner: ater ystem ameContact Name or Phone Number <br /> TYPE OF WORK —New Well Replacement Well n Well Alteration/Modification i Other <br /> 1 Monitoring Well(s) #of wells 1 1 Soil Boring(s) H of borings I Geotechnical <br /> 1 Out-Of-Service Well 1 Out-Of-Service Well Renewal i Cross-Connection Repair RECEIVEf) <br /> ' �Iew Pump 1 Pump Replacement Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION oc I Z ,5 -01 t <br /> Drilling Method`XMud Rotary �❑j Air Rotary 1 Auger i Cable Tool Push Point 1 Other SAN /a� U <br /> Proposed Well Depth �'1t r Excavation t Z in diameter Open Bottom y71`Gravel Pack/Gravej_gizfN��H iwet6' <br /> Conductor Casing in diameter / Conductro�r Casing Depth ft fi OEPAHTIy�N1 <br /> Well Casing Diameter—4.— in Thickness/Gauge/ASTM Sched�F—Z( Steel >Plastic Stainless Steel Other <br /> Grout Seal Depth_ ft i Neat Cement(94 Ib bag/5-10 gal water) >Sand Cement sack mW7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ,x:nriller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width— It Length—=ft Thick in Christy Box Stove Pipe <br /> PUMP ubmersible Turbine Other HP Pump Set It 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 /> MINIMA 24 HOUP ADVANCE NOTICE REQUIRED FOR <br /> � INSfP`ECTIONS- PLEASE CALL(209)953-7697 <br /> C! <br /> SIGNED / `�L TITLE &,14K, DATE /0 <br /> OL 14, <br /> f <br /> I _ <br /> I I <br /> D PARTMENT USE ONLY <br /> c ��'A <br /> Application Accepte y Date Area aq_ _. Employee ID#f:4w-D <br /> Grout Inspection By Date L SPECIAL Well Permit <br /> Pump Inspection By Date ) �►� LI WAIVER Received <br /> Soil Boring Inspection By Date `( l a Constructed Well Depth ft <br /> COMMENTS Q1 j$n/Uc7 W6i�FEAZ&M S J/J �VCC—_i it))L"�L�_ ��13 , i <br /> PE SC Received Check# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Remitted Service Request# <br /> �► �0 251i� 6ROO-Wqy wPou3V911 <br /> .°O Zr-1- S F100 Wo G oo3 Z �P <br /> o V I s 10W0 -7U0 fftj <br /> 4H� `� b I.7� /1(0 ��n I�1I,�/1 qq WELL/PUMP PERMIT <br /> t V�/�l[V <br />