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411 y;o '73c� <br /> WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7597 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> a i 5377 <br /> Joe ADDRESS c,,/ZtP�� `-'^�4'�'� 4Trc. 4 0 <br /> CROSS STREET APN (�V( U _PARCEL SIZE I�0 1 LAND USE APPLICATION <br /> # ,7/ Y p <br /> OWNER NAME , "'�1` _TPHONE �.1 I/0�7-7 '- D 2 <br /> OWNER ADDRESS /V� � / <br /> �',.(((�•••.r n CITY/STATE/ZIP a �'(it "`+�' v 'T <br /> ,^ 7 <br /> CONTRACTOR VAS. `, ` \ n N _ _ �PHONE 1. 2 �'n�O Cq���• <br /> CONTRACTOR ADDRESS Pb �� ~' Cln•/STATEZP t-k1- <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 '1 C-61 i I D-09 (1 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> r!!� <br /> )GOmeslic(Phvate C Irrigation/Agricultural (iIndustrial L,Water Quality Monitoring G Soil Sampling/Characterization <br /> (I Public Water System <br /> It different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK (1 New Well ` replacement Well G Well Alteration/Modification n Other <br /> E Monitoring Well(s) _ #of wells ❑Soil Boring(s) x of bo ngs r_Geotechnical a of bo ngs <br /> C Out-Of-Service Well U Out-Of-Service Well Renewal Ll Cross-Connection Repair <br /> ew Pum -'Pump Replacement G Pump Repair t7 Raise Well Casing <br /> WELL CONSTRUC ON <br /> Drilling Method Pud Rotary G Air Rotary D Auger 11 Cable Tool U Push Point D Other <br /> Proposed Well Depth 6/fO it Excavation Z 94 in diameter Open Bottom r Gravel Pack/Gravel Size in diameter <br /> LI Conduct5f Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sche �Z Steel ')4 Plastic -,Stainless Steel D Other <br /> Grout Seal Depth 1-6 0" it Neat Cement(94 lb bag/5-10 gal water) sosand Cement sack mix/7 gal water <br /> r I Bentonite(20%solids) ',Other <br /> Grout Placement Method Pumped :. Free Fall Other U Retardant i Accelerator(name) <br /> PEDESTAL Installed By ❑Driller :`Pump Contractor 1j1 Other <br /> Concrete Pedestal Dimensions:Width 1t Length it Thick in 71 Christy Box ❑Stove Pipe <br /> PuMP Submersible!;Turbine 1;Other HP Pump Set it Standing Water Level It <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 /> Njify Il UM 24 HO,l1R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)Q953-76897 <br /> SIGNED /j/, L_ TITLE �v DATE <br /> 7 <br /> I AA 1 11 <br /> r, <br /> 1{! <br /> ��r e <br /> . -`,�.�'r . _ — may.-� __ • <br /> _ ] <br /> AN JMA <br /> N 11F OA I- <br /> ARTMENT,DEPARTh1ENT USE ONLY _ <br /> i <br /> Application Accepted By - --Bate Area 5 Employee IDR <br /> Grout Inspection By Date 0 SPECIAL Well Permit / <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By ateC netru te_dWall De th <br /> COMMENTS L✓ <br /> C � E d2. l r,✓ <br /> PE SC Received Choc Amount Date Permit/ Invoice M Well IDM <br /> Codes Info 8 ash Remitted Service Request R <br /> g370 i& G6 4i,Lti� 361lb SPLOD,-75(rg0 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />