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WELL /PUMP PERMIT <br /> SAN JOAeLrtl COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAINSTREET-STOCKTON CA 9520 )488-3420 <br /> NON-REFUNDABLE PERMIT 11 CALL 2097697 FOR INSPECTIONS EXPIRES'I YEAR FRO ISSUED <br /> [CROSS <br /> ADDRESS Ibool 5, I.e.4,rOp QCj N <br /> CITY/ZIP La�'lnrop�� 85330 n <br /> STREET MIpld en cmie AI.ct APN I9I'3 D-I o PARCEL SIZE 3-2��LANG USE APPLICATION#11 ER NAME Ci� cC L 4k ap PHONE �20) C/El/ -72nD <br /> ER ADDRESS 0C,I'(✓Ise lQ C r CITY/STATE/Z1P !!� 95,E o <br /> TRACTOR C WPHONETRACTOR ADDRESS U� L/TR.<-Ge= CITY/STATEIZIP <br /> SUBCONTRACTOR f / PHONE` FILE Cop Y <br /> SUBCONTRACTOR ADDRESS D �61(P CITY/STATEILP <br /> LICENSE IX-57 ❑C-61 D D-09. ❑Other. NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y TOW.Ship_ Range_ Section_ <br /> INTENDED USE ❑DDmestlGPrlVate D Irrigation/Agricultural ❑Industrial 9 Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If difsrenl from Ow sra r ys em ame an eme or no um r <br /> TYPE OF WORK ❑New Well ❑Replacement Well )(Well Afteration/Modi9cation D Other <br /> ❑Monitoring Well($) #of wells ❑Soil Bodn s *&bonne% #&borings <br /> 9( ) O Geotechnical <br /> ❑Oul-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connedion Repair <br /> ❑New Pump ❑Pump Replacement ❑PUMP Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method o Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point 14, Other Peso. Lve 11 Geed S <br /> Proposed Well Depth ft Excavation in diameter C Open Bottom ❑Gravel PacWGravel Size in diameter <br /> KCOnductor Casing 17 in diameter / Conductor Casing Depth G-6 R Sene+vlal: <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schetl1!wC- ❑Steel A'Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 5-6 R ❑Neat Cement(9416 bag/5-10 gal water) Sand Cement 10•'{ sack mixt]gal water <br /> ❑Bentonite(20%solids) O Other 2'1 �<vd.q=a-4 <br /> Grout Placement Method ❑Pumped ❑ Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Duller ❑Pump Contractor ❑ Other <br /> Concrete Pedestal Dimensions:Width 2`It Length R Thick In p9,Christy Box ❑Stove Pipa <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Set R Standing Water Level R <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCrj,T,WITH ALL <br /> WORKERS COMPENSATION WS. M <br /> NIMUM 24 HOUR ADVANCE NOTICE R QUIRE F INSPECTIONS �RECAIP/V <br /> SIGNED TITLE <br /> DATE <br /> 4_p'rl�',J^Qgp$lt <br /> UlAl <br /> d •' <br /> a ylaup .s <br /> S...el.4,aw li d:•r<Y S...a1..6. <br /> e.l.....n e•etay.lanL eti[rtle Tri._ e <br /> • <br /> 4'SRy.51'.p <br /> pe[..yen <br /> '-, n-e` Ea.wle 1.nn 4' <br /> Tut e�..../srl•�c„1� r i .uF�w'w s:y 9... u-... _ <br /> D PARTME US ONLY ^,n <br /> Application Accepted By <br /> Date Area Employee ID# L/tlr <br /> Grout Inspection By �a I SPECIAL WBII Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Constructed Well Depth R <br /> COMMENTS <br /> PE SC Rec.Netl Cheek#/ Amount Date PermiU <br /> Codes Info B Remitted ae Service Re uest# Invoice Well ID# <br /> -7 ��� <br /> „> So6� � ,2 ILE COPY <br /> EHO 43-05 <br /> ap409 WELL RUMP PERMn <br />