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WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY 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 /> /� to <br /> JOB ADDRESS �/ 45– ���'�''- �/t- CITYRmIP Y��C- �� � D <br /> ri . - , LANDU�E(�A�P`-P(SL�IJCAT�ION#CROSS STREET 64 APN 0 0,3 PARCEL SIZE 19,57 <br /> OWNER NAME TA ONEDeh� / _ , <br /> OWNER ADDRESSom <br /> vm <br /> 6: Z n CITY/STATE/ZIP_ r ✓) s�2) <br /> CONTRACTOR /L//i/T r�>!/lsHi /7C PHONE 2e2`1772 '7 '75­7 <br /> CONTRACTOR ADDRESS ��/ CITY/STATE/ZIP�,�1T/ <br /> SUBCONTRACTOR (i /� _ �/r/ /� �� >�`% � _ !PHONE <br /> SUBCONTRACTOR ADDRESS�iYf/ `C S CITY/STATE/ZIP <br /> 7/J � <br /> LICENSE KC-57 r C-61 1 D-09 [1 Other NUMBER `v �L/ EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 'Domestic/Private ❑ Irrigation/Agricultural C] Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> [l Public Water System <br /> If different from Owner: Water System Name ---------C—OntEFCt Name or Phone Number <br /> TYPE OF WORK ❑ New Well I Replacement Well ❑ Well Alteration/Modification A Other ,( • <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) f2 of borings Li Geotechnical #of boringsL,i ( <br /> ❑ Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pum r; Pum Replacement Pum Repair <br /> 11Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool C] 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 Thickness/Gauge/ASTM Sched ❑ Steel L1Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft 11 Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> [..I Bentonite(20%solids) 'I Other <br /> Grout Placement Method [.l Pumped Cl Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller _ Pump Contractor ❑ Other <br /> Concrete Pedestal :'Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP SubmersibleU Turbine r; Other HP Pump Set1y(} ft Standing Water Level ft <br /> I HEREBY CE14TIFY 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 l-AWS. <br /> MIZMI�,rUR ADy�NC TICE REQUIRED FOR INSPECNS- PLEASE CALL(209)953-7697 <br /> SIGNED _JOTITLE ���/yG DATE 1 7 <br /> 31 <br /> J�` <br /> O O Q <br /> ^DEPARTMENT USE ONLY <br /> Application Accepted By f �/ V 1.---- Date Area y /�f Employee ID# <br /> Grout Inspection Bynn Date l 2 q [I SPECIAL Well Permit � <br /> Pump Inspection By Ulan uw Date o 1 J) o \ ❑ WAIVER Received <br /> Soil Boring Inspection By _ Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received I Check#/� Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B C S Remitted Service Request# <br /> tl5�z USU 515 77 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4130/12 <br />