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WELL/PUMP PERMIT <br /> `3AN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMLI!7 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)46&3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED In <br /> �J{� /� t tQf L CITY21P,�S C-GC=�p�ti <br /> JOB ADDRESS -7 o77 c? �� - --- O <br /> 0�A-(?- -APN [.9`�.�Q= 7-PARCEL SIZE 23 LAND USE APPLICATION <br /> CROSS STREET` p7 -- TQ <br /> OWNER NAME �-7\1Y l�apV F r1� ` • �PHKO�N.E �Z'y977�0p <br /> OWNER ADDRESSJ�7��`1_T/�. r�t 11 hH CfTV/STATE21P�;ssa..;a <br /> CONTRACTOR �Q SoL�IS �V`lt-It ._ __.--_ PHDNES���7� <br /> CONTRACTOR ADDRESS L 9 I ilae4tis__— -- ------ CITY/STATE/ZIP- <br /> ----SUBCONTRACTOR _ ._._____ - PHONE <br /> SUBCONTRACTOR ADDRESS _ CrrY/STATE/ZIP <br /> I <br /> LICENSE C-57 C-61 D-09 Other__ NUMBE EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE >&�mestic/Private Irr(gatioNAgricultural Industrial Water Quality Monitoring Soil Sampling/Characterizabon <br /> Public Water System <br /> 11 d#erent Iron Owner: eler yslem ame ------ -entad tune a u r <br /> TYPE OF WORK New Well 'Replacement Well Well AlterationlModification Other <br /> Monitoring Well(s) #Of Wells Soil Boring(s) 'of"i"';s Geotechnical •of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method><Mud Rotary Alr Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth It Excavation / 7- in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter YO_in Thickness/Gauge/ASTM Sched'4n Steel XPlastic Stainless Steel Other <br /> Grout Seal Depth/.0 0 It Neat Cement(94 Ib bag/5-10 gal water) Sand Cement _sack mixl7 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 It Thick in Christy Box Stove Pipe <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI UM�t2/)4 HOUR AD NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED G /C�/J`�O _ TITLE NAL" DATE <br /> 0 <br /> I Q N <br /> EA T <br /> IL <br /> -1 DEPARTMENT USE ONLY <br /> Application Accepted By / AreaEmployee ID# <br /> Grout Inspection 8 Date dllU SpeC1AL Well Permit <br /> Pump Inspection By Dale n WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well D pth_ ft <br /> COMMENT <br /> N .,,koil <br /> PE Be! Received Che Amount Date PermiU invoice# Well ID# <br /> Codes info B Remitted Service Re,uest# <br /> Wo 1 D a9�� S, seoo7a193 <br /> EHO 43-06 WELLIPUMP PERMIT <br /> 4/30/12 <br />