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ATO <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3428 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS !! AE'i I t/�a Cm2 <br /> CROSS STREET V � ,1�r�.A�PNI-gig <br /> 030 ff! PARCEL Sim LAND USE APPLICATION# <br /> OWNERNAME / // //�L PHONE <br /> OWNER ADDRESSTVSft ,_- CrrY/STATE/ZIP_SgW.9F_ <br /> CONTRACTOR +� /per/ J—� �'jn _ G PHONE <br /> CONTRACTOR ADDRESS T�/Z4k;*C ,� CrrYBTATE1Z <br /> SUBCONTRACTOR �� � lE PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE XV57 C-61 D-09 Other NUMBER746aD RL EXPIRATION DA <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y___._. Township Range Section <br /> INTENDED USE omestic(Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterizabon <br /> Public Water System <br /> If different from Owner Water System Name Uontact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> MonitoringWell(s) III of wells SoilBoring(s) #of borings Geotechnical #ofborings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> ew Pump 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 It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thidmess/GaugetASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(941b bag/5-10gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL installed By 3-4triller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length It Thick in Christy Box Stove Pipe <br /> PUMPAoSubmersible Turbine Other HP Pump S ft Standing Water Level It <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 COMPE�24 <br /> ON LAWS. <br /> MINIMUHOUR ADVANC E REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> NED TITLE DATE le'�— Z77_ <br /> PIN <br /> VED <br /> r <br /> 20117 <br /> PAYEH <br /> RECEIV WCESL1H <br /> App, 07 <br /> SAS JOAQUIti 0 <br /> E�RONM <br /> HEA,TH DEP <br /> rTF-# 111 11 _ 717T <br /> P,i1 TMENT UY //J /►�, <br /> Application Accepted B ate Area Employee I V W <br /> Grout Inspection By Date I i SPECIAL Well Perrnit� <br /> Pump Inspection Be ~ Date WAIVER Received <br /> IF <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service est# <br /> Aw oSV 4-147 W P u"'M�W5 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4!!0/12 <br />