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N« o ; <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT r CALL 209 953-7697 FOR INSPECTIONS /EXPIRES 1 YEAR FROM <br /> rDATE ISSUED <br /> JOS ADDRESS TV L 7 tC <br /> , Ai CITYIZiP '7 ,:r (L/ I J rn <br /> D <br /> CROSS STREET ' APN '✓1 L-U l <br /> 3 PARCEL SIZES 4r r•f LANG USE APPLICATION# m <br /> OWNER NAME V-0 C at H C I "I PHONE m <br /> OWNER ADDRESS CS. M� CITY/STATE/LP <br /> l! <br /> CONTRACTOR QI - r n err P (^ <br /> HONE 7G6��}J�1�(Xl <br /> CONTRACTOR ADDRESS Z Crrr1STATEIZJP L-j-, �^, �) l5 L-!r/ <br /> SUBCONTRACTOR ,V /j I A, PHONE <br /> SUBCONTRACTOR ADDRESS /°/N CrTY/Sr�IlTATEIZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER q 450 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE IDomestic/Private ' Irrigation/Agricultural Industrial Water Quality Monitoring XSoil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water system Name me ame or ne umber <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification ,Other <br /> Monitoring Well(s) #of wells Soil Boring(s) a of borings .Geotechnical 2 Itof borings <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 Air Rotary Auger Cable Tool Push Point Other R C <br /> Proposed Well Depth I� ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size ri <br /> If Casing in diameter Conductor Casing Depth ft / „_ <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel �4%ef <br /> Grout Seal Depth ft Neat Cement 94 Ib bag/5-10 gal water) Sand Cement -/y�E /v ter <br /> Bentonite(20%solids) >(Other S - ban 4(r;I t I, 7h/n� �ENt <br /> Grout Placement Method Pumped.A Free Fall Other Retardant!Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width_It Length 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. 1 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 COMPENSATI,OiN�'WS. <br /> MINIM I�QL1R DVANCE NO ICE REQUIRED FO(R' INSPECTIONS PLEASE CALL(209)953-7697 <br /> SIGNED TITLE ell Il741JCC/ rl DATE ! <br /> EPARTMENT /USE ONLY Wo <br /> Application Accepted By A4Data. IO-��"I 0 Area "/L Employee ID# <br /> Grout Inspection By 111640AIMrbNiiU Date - �J-( SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Ins�;ti By Date Constr};cI d Well Depth ft / <br /> COMMENTS / rr r �VlS1LP�� n< 11A .1 <br /> PE Sc Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes info B ash Remitted Service Request# <br /> 437 z ISO dN- Zz.zqr pp 0 3, 1)F, <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/70/12 <br />