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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NO. PERMIT CALL 209 953-7697 FOR INSPgpTlqffq <br /> LA <br /> 1 YEAR FROM DATE ISSUED <br /> RIC <br /> '--t G �(�`'�'7 mJQ'3 ADDRESS ,7<�C)r� �� �� CITY2IP t��r1 � � <br /> m <br /> D <br /> CROSS STREET Y APN \ �" _ PARCEL SIZLAND USE APPLICATION# m <br /> N <br /> OWNER NAME L PHONE <br /> dlL <br /> OWNER ADDRESS 6�0 CITY/STATERIP <br /> CONTRACTOR ' PHONEaft i _I 14 <br /> CONTRACTOR ADDRESS L CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 I C-61 D-09 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDEDUSE % Domestic/Private Li Irrigation/Agricultural I I Industrial i Water Quality Monitoring I i Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK I New Well i I Replacement Well i I Well Alteration/Modification Other <br /> 13 Monitoring Well(s) It of wells I Soil Boring(s) #of borings I i Geotechnical If of borings <br /> I I Out-Of-Service Well I I Out-Of-Service Well Renewal 1 Cross-Connection Repair pA YM <br /> New Pump i Pump Replacement I Pump Repair I Raise Well Casing1 <br /> WELL CONSTRUCTION <br /> Drilling Method .I Mud Rotary I Air Rotary i I Auger i Cable Tool i Push Point i Other 4• <br /> Proposed Well Depth ft Excavation in diameter Open Bottom I Gravel Pack/(�ravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft 'NV AQIJ/N <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless /RQ OU <br /> Grout Seal Depth it i Neat Cement(94 Ib bag/5-10 gal water) Sand Cement HAID) /x/7 gal water <br /> Bentonite(20%solids) I Other �p <br /> Grout Placement Method 1 Pumped 11 Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor i Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level Z 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 WIT ALL <br /> �( 0 KE CO N YAWS. <br /> �t�/'`�'1 IMUM NOTICE RTAKff9ED FOR IN IONSS- PLEASE CALL (209) 953-76 <br /> SJGtEii / TITLE /J DATE <br /> I <br /> CJ j <br /> ALL <br /> t <br /> l <br /> EP T M E N T USE NLY <br /> A <br /> Application Accepted By Date l� Area Employee ID# <br /> Grout Inspection By n� Date Ll SPECIAL Well Permit <br /> Pump Inspection By Date I I WAIVER Received <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 Cash Remitted Service Request# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />