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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �y N <br /> G <br /> JOB ADDRESS CITY/IJP �^�L?L _/C`l►tLl �j /i/ m <br /> /� f!- m <br /> 7 O <br /> CROSS STREET y/_ APN_JGI <br /> J-J 7U--CJ 2- PARCEL SIZE I/- I_LAND USE APPLICATION N 9 <br /> OWNER NAME d'it /%F} PHONE <br /> OWNER ADDRESS YP4j` _ CITY/STATE/LIP E°-�/'hy /I t/4/fir/O <br /> CONTRACTOR rc.�.�_f- 5/y7 PHONE SSR- F7?If <br /> CONTRACTOR ADDRESS P U I CITY/STATE/ZIP 42"aiL. f,I <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS �C/I-TAY/STATTE/ZIP <br /> LICENSE .4-C-57 C-61 D-09 Other NUMBER f)/ tc-I EXPIRATION DATE w <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE Domestic/Pnvate irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> 11 C17ferent from Owner W.ter System Name — ntect ame or one um r <br /> TYPE OF WORK New Welt . Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) If of wells Soil Boring(s) s of bonne. Geotechnical N of bonngs <br /> XOut-Of-Service Well _ Out-Of-Service Well Renewal Cross-Connection Repair <br /> 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 tt Excavation in diameter Open Bottom Gravel Pack/Gravel Size In diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schell Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mixr7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped . Free Fall I Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width it Length it Thick in Christy Box ._Stove Plpe <br /> PUMP Submersible. Turbine Other HP Pump Set It 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 LA <br /> MIN M 24 H���DVENOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE � DATE <br /> E <br /> ) <br /> DEPA TMENT/U-- �/ Y <br /> a <br /> Application Accepted By • Date Area Employee IDp � <br /> Grout Inspection By_ Date = SPECIAL Well Permit <br /> Pump Inspection By. Date /2— WAIVER Received <br /> Soil Boring Mpectionl3y Dat Constructed Well Depth It <br /> COMMENTS <br /> PE Sc Received CC�� Amount Date Permit/ Invoice S Well ID# <br /> Codes Info By Cash Remitted Service Request k <br /> 7 ( ; �Zfc" o s q o bqqqZ, <br />