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WELUPUMP PERMIT C I,- t <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTGN CA 95205 - (209)468-3420 <br /> "NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS l/V (/ (/ 1�f- Lam _ CITY/ZIP � _ �J/J�5 3 m <br /> CROSS STREET a 5 ^ /' , V (O o <br /> /" APN b O P PARCEL SIZE LAND USE APPLICATION# M <br /> ��� <br /> OWNER NAME 0_' O-/(/n�� � i `G PHONE = J`2- y <br /> OWNER ADDRESS ! I" CITY/STATE/ZIP.__ <br /> CONTRACTOR b-J� `�>/I •S �l/�1 PHONE 3 3 <br /> CONTRACTOR ADDRESS r v rV 37 I ��f _ CITY/STATE/ZIP 14—A- C <br /> SUBCONTRACTOR _ c��t _ PHONE <br /> SUBCONTRACTOR ADDRESS _ CITY/STATE/ZIP <br /> LICENSE -57 C-61 D-09 Other._- NUMBER "= ' /ri <br /> _� 1.-. EXPIRATION DATE — <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y _ Township _ Range----,— Section--____. <br /> INTENDED USE 1 Domestic/Private rrigation/Agricultural Ll Industrial ❑ Water Quality Monitoring I I Soil Sampling/Characterization <br /> I 1 Public Water System <br /> If different from Owner: Watef�em Name Contact Name or hone um er <br /> TYPE OF WORK -<NeW Well Replacement Well ❑ Well Alteration/Modification Other N �/A.,„,"_ <br /> ❑ Monitoring Well(s)_ #of wells Ll Soil Boring(s) #of borings Geotechnical ry..�ow"ZfIll <br /> 11 Out-Of-Service Well Li Out-Of-Service Well Renewal 11 Gross-Connection Repair ' ��P SIE® <br /> ew Pump I Pump Replacement ❑ Pump Repair ❑ Raise Well Casing .I <br /> WELL CONSTRUCTION 18 <br /> Drilling Method>cMud Rotary I Air Rotary I' Auger Cable Tool Push Point n Other SAN jO 10 <br /> 1Z TV / SIN <br /> Proposed Well Depth____�_j)ft Excavation _Lc,/ In diameter Open Bottom KGravel PacWI2R VP`�IMEWAL-in diameter <br /> Z-7 <br /> Conductor Casing in diameter / Conductor Casing Depth _ _ ft ^DEPARTMENT <br /> Well Casing Diameter? in Thickness/Gauge/ASTM Sched__'-,� Steel *O�Plastic Stainless Steel Other <br /> Grout Seal Depth__S') ft Neat Cement(94 lb bag/5-10 gal water) >CsandCement 3 sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method 74pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By -'*-"Driller Pump Contractor Other 1i <br /> Concrete Pedestal Dimensions:Width�'_ft Length ft Thick ' in Christy Box Stove Pipe <br /> PUMP -'—Submersible Turbine Other HP1,0 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 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 /> MINI UM 24 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209)953-7697 <br /> SIGNED -_=7 - TITLE �C.✓R1'- DATE -ZL) - -- <br /> �� <br /> E7 R T M E N T U S E ON L Y / <br /> ^pplicalio <br /> .Accepted p. A Date Cl / t9 _ Area_ - Employee ID#�'/,tV/ <br /> Grout Inspection By i ' Date :2�421 19 ❑ SPECIAL.Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received h Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Request# Invoice# Well ID# <br /> c <br /> GiT /ya7g 00, J, /O/a a ; 15.3 <br /> 2 c - ' <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />