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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 /> rn <br /> JOB ADDRESS r kj� CrfY/ZIPcLey-) <br /> a <br /> 0 <br /> CROSS STREET AP �S I PARCEL SIZE _LAND USE APPLICATION# °v <br /> ^� N <br /> OWNER NAME C�. 'y �/ PHONE /'meq <br /> OWNER ADDRESS Y' CITY/STATE/ZIP5 � (`�� ' <br /> CiW 1 OV ` GI <br /> CONTRACTOR tt�� / {' PHONE <br /> CONTRACTOR ADDRESS S CITY/STATE/ZIP �A 1 v� ✓ r� 9 ) LJ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYG/�STATE/ZIP r1 <br /> LICENSE C-57 L C-61 U D-09 U Other NUMBER I • EXPIRATION DATE L C( <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE A Domestic/Private 7 Irrigation/Agricultural 0 Industrial ]Water Quality Monitoring C Soil Sampling/Characterization <br /> U Public Water System <br /> If different from Owner. Water Systern Nam on Nam or one N.Mb.r <br /> TYPE OF WORK>CNew Well L Replacement Well U Well AlteratioNModification U Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #ofborings D Geotechnical #ofborings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well R I Cross-Connection Repair <br /> U New Pump L Pump Replacement U PumpReo�;- Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)CMud Rota C Air Rotary Other <br /> Proposed Well Depth 2_V ft C I U Gravel Pack/Gravel Size in diameter <br /> Fi Condu or Casin J <br /> Well Casing Diameter in Thicknes tic f1 Stainless Steel -1 Other <br /> Grout Seal Depth C /► Cement sack mix/7 gal water <br /> Bentonite(20%solids) L I. •WA/�r �` <br /> Grout Placement Method XPumped ❑Free F \��i✓ 'erator(name) <br /> PEDESTAL Installed By 7 Driller C Pu <br /> ❑Concrete Pedestal DDimensit in D Christy Box ❑Stave Pipe <br /> PUMP ❑Submersible]Turbine C Othe Pump Set _ft Standing Water Level It <br /> 1 HEREBY CERTIFY THAT I HAVf�PREPARED ', ,iiON AND THAT TE'- BE DONE IN ACCORDANCE WITH SAN <br /> JOAQ 1 COUN O DINANC@$(ST LAWS, ...� RULES AND REGUI• `TIFY THAT MY REQUIRED LICENSE IS <br /> CUWD <br /> E WIT HE II O TORS STAT 4AT I AM IN COMPLIANCE WITH ALL <br /> WO <br /> 4 H DVA CE NOTICE SE CALL(209)953-[7-697 <br /> SIG \' DATE I ll Y41 <br /> psi/• <br /> I <br /> H p�NMeN/V ry <br /> PART rot <br /> D ARTMENT USE ONLY j <br /> Application Accepted By ate �S "f'� Area__ /' EmpioyeelD# <br /> Grout Inspection By 4r Data ❑ SPECIAL Well Permit / <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection 8 Constructed Well Depth ft t <br /> COMMENTS �d <br /> 9 <br /> PE SC Received h Amount Permit/ a10/L <br /> Codes Info B Cash Remitted Date Service Request# Invoice# WellID# <br /> :43 bb )�a 116.Z- 1115 -� P0b3775q(v <br /> EHO 43-06 WELL/PUMP PERMIT <br /> 4/30112 <br />