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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 ISSUED <br /> JOB ADDRESS 1/, P, CITY21P A v CA Y n 0 jf..2.Z1/ m <br /> D <br /> rnG•�(�1SI�D'AU� ' S ( Q /(�If+ UCROSSSTREET APIN PARCEL SIZE - LAND USE APPPLICATION# <br /> p / -L ( KOWNERNAME fHONE Z •LPa2-& Za <br /> OWNER ADDRESS / CITY/STATE21P y�lal � <br /> CONTRACTOR PHONE <br /> /og.i119 � 7,( <br /> CONTRACTOR ADDRESS -0- TATE21P M j y, <br /> aN <br /> oKy <br /> SUBCONTRACTOR 1 V PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STAT <br /> E/ <br /> ZIP dJ <br /> LICENSE C-57 L C-61 U D-09 U Other NUMBER ��t.✓ EXPIRATION DATE ` L ul <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE Domestic/Private ]Irrigation/Agricultural ❑Industrial 7 Water Quality Monitoring E Soil Sampling/Characterization <br /> U Public Water System <br /> If different from Owner Water tipterri Narne Contact Name or Vn.ne Number <br /> TYPE OF WORK D IVeW Well L Replacement Well U Well Alteration/Modification - U Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> U New Pump L Pump Replacement U Pump Repair U Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)III(Mud jpta C Air Rotary E Auger :1 Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth ft Excavation I in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter <br /> n Conduc r Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter. in T((hyycld ass/Gauge/ASTM Schad al n Steel kPlastic n Stainless Steel ]Other <br /> Grout Seal Depth R U EN eat Cement(941b bag/5-f0 gal water) ❑Sand Cement sack mixfl gal water <br /> Bentonite(20%solids) L Other <br /> Grout Placement MethodXPumped ❑Free Fall E Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ]Driller E Pump Contractor ] Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible]Turbine C Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CE FY AT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN C DINANCES, ATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURR A I WITH CA ORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WOR P S TION Lou <br /> M 4 OT ED FOR IN�S �u�l�PEC IQNSI-1 PLSE CALL(209)9 <br /> EA7697 <br /> SIGN TITLED�t r�I' rDATE �� I :4 <br /> RF����Fiyp <br /> Nps,?g FD <br /> \ �0 <br /> ✓0 1� <br /> ryo pN�N�, <br /> MENT <br /> _ ,,P7EPARTMENT USE ONLY g ! N <br /> Application Accepted By ate Area C� 1 Employee ID# / <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspe tion By Date` Constructed Well Depth .�©V ft nol <br /> COMMENTS L S i S I i Jl 1 ' % 7 /y <br /> ?CG <br /> C I it1�Q t�ti <br /> PE Sc Received (QWkil Amount ate Permit/ Invoice# WeIIID# � � r <br /> Codes Info B ash Remitted Service Request# <br /> L43G:E )t G /IJ(o 3</3 <br /> -93q lys <br /> g3�iU <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />