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t WELUPUMP PERMIT <br /> SAN J`AOUiN 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 h�IIA LI -fes U L CITY/ZIP_�7��C�/(�N ✓ m <br /> el <br /> CROSS STREET 7 'Q�r L,G�J 17 APN C? V D PARCEL SIZE LAND USE APPLICATION# M <br /> m <br /> cn <br /> OWNER NAME C �.t�Gc LL a L PHONE xy 0�/:5 <br /> OWNER ADDRESS r2 t 194-eelLy CITY/STATE/ZIP !C/C� T,1A_1 <br /> CONTRACTOR �%7/� / y //1�G ' /PHONE ,:,,1Z" / 7 7Z_ - 2-75-7 <br /> CONTRACTOR ADDRESS Y>LGT�7�C�L�/r / _ CITY/STATE/ZIP �/� iC�J //rlZ/3 C�q <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATECITY/STATE/ZIP <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 01761746EXPIRATIONDATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X _ Y _ Township Range Section <br /> INTENDED USE /-Domestic/Private Irrigation/Agricultural ❑ Industrial I Water Quality Monitoring Soil Sampling/Characterization <br /> 11 Public Water System__ _ <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 7 New Well Y Replacement Well ❑ Well Alteration/Modification Other <br /> 'l MonitoringWells 4 of wells ❑ Soil Boring(s)s #of borings #of borings <br /> O g( ) Geotechnical <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement ❑ Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method )( Mud Rotary I I Air Rotary Auger IJ Cable Tool Push Point Other <br /> Proposed Well Depth 2&e) ft Excavation �?��y in diameter Open Bottom Gravel Pack/Gravel Size 3 /rte in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth / ft <br /> —, <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 502 Z/ ISteel ,T Plastic 17 Stainless Steel Other <br /> Grout Seal Depth_ 11 ft Neat Cement(94 Ib bag/5-10 gal water) XSand Cement IO 3 sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method A Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 7XDriller I Pump Contractor Other <br /> /Concrete Pedestal Dimensions:Widttr/`- ft Length S ft Thick�_in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set__/&1, ft Standing Water Level I 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 21;; ADVAN ENO EGIUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7697 <br /> SIGNED .� TITLE � ����7LDATE <br /> FCO <br /> J <br /> / C <br /> i I i i 1 i l i 1 1 i i 1 1 1 i l l l l i i l <br /> D E A R T M E NT USE ON / <br /> Application Accepted By A ' Date b Area Employee ID# <br /> Grout Inspection By A".w441n�– Date Y ❑ PECI L Well Permit <br /> Pump Inspection By � 4�UDQ -QN Date O' << ❑ WAIVER Received <br /> Soil Boring Inspection ByDatp Constructed Well Depth ft <br /> COMMENTS 1s� ��'� �/�(� 57eratp-, <br /> PE Sc Received Cl Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash RemittedService Request# <br /> w�'C Ale <br /> EHD 43-06 �]�/1.-Si WELL PUMP PERMIT <br /> 4/30/12 / 7 <br />