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t ' { WELUPUMP PERMIT <br /> SAN JOAOUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NO'N-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> n L J / � /�,,� f N <br /> JOB ADDRESS I c/ r��VR 1 /L CITY/ZIP -7-rp�L/CJ� Ci1" l/��� m <br /> - D <br /> / ) v <br /> CROSS STREET J 9/<< L,4 AJ)7 APN 1_ >_l__ L PARCEL SIZE LI LAND USE APPLICATION# m <br /> m <br /> --- -- - ZV (39- 337 <br /> OWNER NAME rr �� �tt- t-L P t- PHONE. A <br /> OWNER ADDRESS ��}."/��7 A t2l/9&'(P AA C/Le. CITY/STATE/ZIP 125 Z/S <br /> CONTRACTOR /� �J g1 �� ` //)ZG _ _._ '/PHONE l / 7 7Z 2-75— <br /> CONTRACTOR ADDRESS Y� XML �7 wG'��'/ / CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 C-61 D-09 I Other NUMBER l /5)! EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE /-Domestic/Private Irrigation/Agricultural [I Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br /> 1 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ] New Well X Replacement Well ❑ Well Alteration/Modification Other <br /> ❑ Monitoring Well(s) It of wells I I Soil Boring(s) — #of borings Geotechnical__ #of borings <br /> ❑ Out-Of-Service Well 1 Out-Of-Service Well Renewal U Cross-Connection Repair <br /> New Pump U Pump Replacement I Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method )r Mud Rotary ❑ Air Rotary Auger F, Cable Tool Push Point Other <br /> Proposed Well Depth 2C-6 ft Excavation in y in diameter Open Bottom ,i Gravel Pack/Gravel Size 51l_{—in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter--&,in Thickness/Gauge/ASTM Sched 5bj2 Z/ U Steel ;'Plastic Stainless Steel I Other <br /> Grout Seal Depth71 _ft Neat Cement(94 lb bag/5-10 gal water) XSand Cement lC' 3 sack mixd7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method A Pumped ' Free Fall n Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 'XDriller Pump Contractor Other <br /> /C Concrete Pedestal Dimensions:Widtlr, �ft Lengt S ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP 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 /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 2 ADVAN E NO EQUIRED FOR INSPECTIONS-PLEASE CALL (209)9553-7697 <br /> SIGNED 7 TITLE "-' fes' G� DATE <br /> ILI <br /> AIV <br /> J <br /> 71 C <br /> Fq C <br /> D E ARTMENT USE O NY <br /> Application Accepted By , A ' Date b Area Employee ID# W ,AV/fyA <br /> Grout Inspection By �/�Qa kn-w/� —eE' I Date �d /U U PECIAL Well Permit <br /> Pump Inspection By 6 1 ���� ���Q 111 N Date'. V '�'v l °\ F1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS sT <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> -? <br /> S2. Uj <br /> EHD 43-06 ` �]^1 /G�i WELL/PUMP PERMIT <br /> 4/30/12 /`7 <br />