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WELUPUMP PERMIT �� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 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 �LteC.�-D_—.��..��� �----- — CITY21P.5k-2�-- <br /> 0 <br /> ��••w 0 <br /> CROSS STREET�:.SAl. �y� `�.—��nPN- _._PARCEL SIZE LAND USE <br /> jAPPLICATION N_` ._— a <br /> OWNER NAME B-a-�Jj6''��}} Ac PHONE <br /> —.2` <br /> OWNER ADDRESS -V_—LY_t,eu � A <br /> _A -�.-- ..... CITY/STATE/ZIP _-- <br /> CONTRACTOR �Jo-PHONE�� <br /> CONTRACTOR ADDRESS 11•� '✓�~S _-_. CITY/STATE/ZIP„G O <br /> SUBCONTRACTOR .___—___. ___._ —____ _ _.._ PHONE <br /> SUBCONTRACTOR ADDRESS __ CrrylSTATE/ZIP_- J _ <br /> LICENSE C-57 C-61 D•09 Other NUMBER `w_ EXPIRATION DATE,Q[, O� <br /> GEOGRAPHICAL INFORMATION: Coordinates X YTownship_ Range—_ Section— <br /> INTENDED USE OomestictPrivale Irrigation/Agricultural Industrial Water Quality Monitoring Soil SamplinglCharacterization <br /> Public Water System_ <br /> If different from Owner. -- aleYJ f flame=--`------ —Cpnidd Flame or wno Number <br /> TYPE OF WORK XNew Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s)_---#of wells Soil Borings) _ "Of bunngs Geotechnical _--"of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Crass-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth,� It Excavation 7e L in diameter Open Bottom <Gravel PacWGravel Size in diameter <br /> Conductor Casing-_ _•—in diameter_/[COndUCtO CasingDepth----'—ft <br /> Well Casing Diameter L In Thickness/Gauge/ASTM SchedPlastic Stainless Steel Other <br /> Grout Seal Depth. —_ It Neat Cement(94 Ib bagr5-10 gal water) Sand Cement-/Q1_„1—sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method umped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length ft 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED___ -L L. ,✓ _._--______._____ TITLE_ <br /> DATE <br /> _-{_�� J <br /> �2Zr , __ <br /> — <br /> C <br /> E fly CC U <br /> L I{ 4iL <br /> ----------- 1 <br /> -ITHI <br /> DEPARTMENT USE O LY <br /> Application Accepted By / Date_ / Area < Employee ID# �( Z/ <br /> Grout Inspection y Date...� - SPECALWell Permit <br /> Pump Inspection By —_ _ Date WAIVER Re <br /> --- celved <br /> Soil Boring Inspection By Dale -- Constructed Well Depth <br /> COMMENTS -- <br /> PE SC Received Amount --- Permit/ — <br /> Codes -Info- B — dash Remitted Date Service Request# Invoice# Well ID,# <br /> l >f <br /> EHO'lYOu <br /> .rr7n:12 WELL'PUMP FEPXV; <br />