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WELUPUMP PERMIT <br /> :SAN JOACION COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT C[A��LL�� 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE TISSUED <br /> JOB ADDRESS `'t1'a �1�J�tN K.V CITY/ZIP Ji ! J LC/ N <br /> m <br /> D <br /> CROSS STREET Ab APN ill-C(C C05 PARCEL SIZE 45' LAND USE APPLICATION# 33 <br /> OWNER NAME V�TpI✓2W MIC % PHONE 2 b9 /���� ,1 <br /> OWNER ADDRESS /-,� J -1� CITY/STATE21P 4iLk/'0j4S�TM1&jI tJ f ��Y <br /> CONTRACTOR �J / 7PIWID A/&�' �S- ��J�" � � PHONE (. <br /> CONTRACTOR ADDRESS <br /> a Ali )Q C� Ic-3 . CITY/STATE/ZIP ` �/0� 7 J �j & <br /> SUBCONTRACTOR l_J�V/Ve'4- /y5 //IL-�WTt /�'' PHONE -77 �[�� GL� <br /> SUBCONTRACTOR ADDRESS I, (�AK�S�D>= { a"Ie CITY/STATE/ZIP Aly gef&-11 <br /> LICENSE C-57 C-61 I I D-09 Other NUMBER EXPIRATION DATE 3 3i J <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 1 Domestic/Private .Irrigation/Agricultural '_i Industrial Fi Water Quality Monitoring i I Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Name Conlact Name or Phone Number <br /> TYPE OF WORK )CNew Well I Replacement Well Well Alteration/Modification I i Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well 1 Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump i Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method i Mud Rotary 1 Air Rotary ;Auger Cable Tool Push Point i Other <br /> Proposed Well Depth (05 ft Excavation Z(v in diameter IOpen Bottom )LGravel Pack/Gravel Size in diameter <br /> Vt_Conductor Casing 'ZZ) in diameter / Conductor Casing Depth 'C2 d`f ft <br /> Well Casing Diameter I� in Thickness/Gauge/ASTM Sched -7,5-47 Steel Plastic ;(,Stainless Steel Other <br /> Grout Seal Depth Zo ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement it sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method . umoed Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> XCOncrete Pedestal Dimensions:Width__41_it Length =jjL=ft Thick 7 in Christy Box Stove Pipe <br /> PUMP Submersible KTurbine Other HP L' Pump Set `n ft Standing Water Level 1G, 5—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 H THE CALIFOR A CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CO ENSATI <br /> MI A V CE TICE REQUIRED FOR IN PECTIONS - PLEASE CALL(209)953-766;9 <br /> SIGNED eVUTITLE DATE <br /> f <br /> r <br /> I <br /> r <br /> J <br /> y N <br /> I 1 P A 110, <br /> DEPARTMENiL <br /> T U S E O N L Y <br /> Application Accepted By ate"I 5- Area �' �' Empluyee ID# <br /> Grout Inspection / Date - / / _ ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ! IX WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS 1 o,U L-c- 5kkL( f>w— tr�i� SYo % "a, CAM ` -.40PczL � 6� �- y.,,( �iikat,.�f <br /> PE SC Received CheckW Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Reg uest# <br /> 136.1, so A( 3767--3 i di I A> 3 /s 52-06 _))'�61C'CC vV pao3lP zg 5 <br /> 37� 23 T) 3 l5— anb, 3q3 0I <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />