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WELUPUMP PERMIT' <br />SAN JOAQUIN 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 <br />ISSUED <br />JOB ADDRESS 1 _� �i , I 1 W L/ la CITY/ZI q/�-3-7 <br />CROSS STREET .L �i�PN 1& PARCEL SIZE I '/V LAND USE APPLICA AON # <br />OWNER NAME % 1 PHONE �N_j q]^ 71A��✓,/ <br />OWNER ADDRESS CITY/STATE/ZIP V <br />CAO <br />CONTRACTOR PHONE Yj6N-3,_-_41 l / <br />CONTRACTOR ADDRESS � CITY/STATE/ZIP <br />C4 /9.CJ! <br />SUBCONTRACTOR 4 oe 4 PHONE <br />SUBCONTRACT R ADDRESS 47't- CIT /STATE/ZIP <br />LICENSE -57 (1 C-61 i 1 D-09 [I Other NUMBER EXPIRATION DATE / <br />GEOGRAPHI AL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE Domestic/Private G Irrigation/Agricultural CJ Industrial ❑ Water Quality Monitoring U Soil Sampling/Characterization <br />I I Public Water System <br />If different from Owner: Water System Name-------- C—ontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ll Replacement Well 0 Well Alteration/Modification D Other <br />❑ Monitoring Well(s) # of wells 0 Soil Boring(s) of borings C Geotechnical � f T <br />❑ Out -Of -Service W II U Out -Of -Service Well Renewal [jCross-Connection Repair CEjVE® <br />Fl. New Pump Pump Replacement ❑ Pump Repair n Raise Well Casing <br />WELL CONSTRUCTION 2018 <br />Drilling Method U Mud Rotary D Air Rotary U Auger Ll Cable Tool U Push Point 0 Other SANJQA <br />Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel PacWGravoJ£ V1R0 71 -11� *eter <br />u Conductor Casing in diameter / Conductor Casing Depth ft EPARTMENT <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 'i Steel 0 Plastic ❑ Stainless Steel 0 Other <br />Grout Seal Depth ft l' Neat Cement (94 Ib bag/5-10 gal water) D Sand Cement sack mix17 gal water <br />�.I Bentonite (20% solids) � 1 Other <br />Grout Placement Method i.l Pumped _1 Free Fall F1 Other [1 Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller 17 Pump Contractor U Other <br />Concrete Pedestal :Dimensions: Width ft Length ft Thick in U Christy Box n Stove Pipe <br />PUMP Ik Submersible(; Turbine I; Other HP/iJ Pump Set ft 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 />WORKER$-6,OMPENSAIION LAWS. <br />SIGNED <br />EP RTMENTU E 0 LY <br />Application Accepted By Date 1% <br />Grout Inspection By Date <br />Pump Inspection By Date <br />nII�i(I�i <br />Soil Boring Inspection By Dto <br />COMMENTS �v /L� <br />Area_4�q Employee ID# <br />0 SPECIAL Well Permit <br />0 WAIVER Received <br />Constructed Well Depth ft <br />rn <br />D <br />0 <br />M <br />M <br />m <br />y <br />PE <br />Cod94 <br />SC <br />Info <br />Received <br />B <br />Chec <br />ash <br />Amount <br />Flemitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />EHD 43.06 WELL /PUMP PERMIT <br />4/30/12 <br />