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WELUPUMP PERMIT <br /> SAN 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 /> JOB ADDRESS //c� Q—PdSA 12L/ GITY/ZIP,5_/IJGAc /Ok/ G4 "' <br /> ���� ` j)� v <br /> CROSS STREET �/F/��/�- APN 1/ PARCEL SIZE _LAND USE APPLICATION# <br /> OWNER NAME �j t�IQ�JEs A J `PHONE GC/�/ / /y +/ � // / <br /> OWNER ADDRESS A /Y/I�/�ZPr�S� /�Q CITY/STATE/ZIP <br /> CONTRACTOR 3//�YI_! iG<GC//!//l ��L /PHONE zal 77z 275-7 <br /> CONTRACTOR ADDRESS /0 �� �/L�/ZI�IJ/� ��/ CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS _ CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 I I Other NUMBER _/QI O/ EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE "X Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring i Soil Sampling/Characterization <br /> G Public Water System_ <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical #of borings <br /> ❑ Out-Of-Service Well 11 Out-Of-Service Well Renewal Cross-Connection Repair <br /> X New Pum Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter I Open Bottom Gravel Pack/Gravel Size in diameter <br /> L Conductor Casing _in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel n Plastic LI Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement Sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in i Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP 3 Pump Set—ZY2 ft Standing Water Level 16 ft <br /> 1 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 C RACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI 2 O ADVANC NOTI REQUIRED FOR INSPECT - PLEASE CALL(209)953-7697 <br /> SIGNED TIT E DATE 7--03--07 <br /> �u a <br /> 'AJ.J <br /> DE F LARTMENTSE ONLY <br /> Application Accepted B Date AreaAEmployee ID#��� � <br /> Grout Inspection By p Date Ll I PECIAL Well Permit <br /> Pump Inspection By Date I_I WAIVER Received <br /> Soil Boring Inspection By Date �Constructed Well Depth _ft <br /> COMMENTS�-fv�b'cv��4'11 ✓ '+�1 [ f{ IJot Q i" �� ) <br /> 1- 17 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />