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WELUPUMP PERMIT <br /> S/AN 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 /> Ln <br /> JOB ADDRESS 22 <br /> CITY/ZIP fL�2— m <br /> 07'7-t9t!- <br /> CROSS STREET (�/V�J�i��- �r7 APN .3 p _PARCEL SIZE _LAND USE APPLICATIONrn <br /> En <br /> # � <br /> OWNER NAME PHONE 9,".> <br /> OWNER ADDRESS 4S�M CITY/STATE/ZIP__ -- L <br /> CONTRACTOR / I 1 �0�`� L [ (� PHONE <+t ill- Y �� <br /> CONTRACTOR ADDRESS PV 17 t, CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER?-Y3 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y _ - - Township Range Section <br /> INTENDED USE `,<Domestic/Private Irrigation/Agricultural LI Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System t4ame Contact Name or Phone Number — <br /> TYPE OF WORK 'b'�New Well Replacement Well 1 Well Alteration/Modification Other <br /> ❑ Monitoring Wells) #of wells U Soil Boring(s) #of borings Geotechnical #of borings <br /> Il Out-Of-Service Well ❑ Out-Of-Service Well Renewal � Cross-Connection Repair <br /> New Pump i_1 Pump Replacement Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ,-Mud Rotary A Air Rotary Auger Cable Tool Push Point r1 Other <br /> Proposed Well Depth2F=' ft Excavation / Z . in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter Z� <br /> in Thickness/Gauge/ASTM SchedSteel Mastic Stainle Steel Other <br /> Grout Seal Depth iL0.7, ft Neat Cement(94 lb bag/5-10 gal water) >'Sand Cement l(/. sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method dumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By te Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width 3 ft Length J ft Thick - n Christy Box Stove Pipe <br /> PUMP *--Submersible Turbine Other HP „-,y 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 REOUIRED LICENSE !-- <br /> CURRENT <br /> SCURRENT AND ACTIVE WITH THE CALir'ORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209)953-7697 <br /> SIGNED C—+ — —_ — TITLE—aCUA L _--_ DATE _ ?—Zt�� <br /> cc a <br /> I � �o <br /> a 7s <br /> ilk W <br /> IT T <br /> D �:) R MEN i iJSc vt. CY <br /> Application Accepted By - - ;e V<<7 Area � f-- Employee ID# ^ (� <br /> Grou'Inapacii0:B;, Date -3 ❑ SPECIAL Well Permit <br /> Pump Inspection B Date F1WAIVER R@C@IV@d <br /> Soil Boring Inspection By Date onstructed Well Depth ft <br /> COM NTS off <br /> iy 17DOS <br /> l <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info i `•'Y Cash Remitted Date Service Request# Invoice# Well ID# <br /> (off I 3 v 3 ,y- —ic, 39� _ ��PO 0-563* <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />