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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 /> Joe ADDRESS 1 _.. [\1 ►7 O ! (� CITY/ZIP K/�C' C/1 rr <br /> 11 T <br /> CROSS STREET.Ir I tew'l'l Q J JJ APN Z'I 57 150- L-S _ -PARCEL SIZK? Lr c',�LAND USE APPLICATION# <br /> rr <br /> OWNER NAME r L /-raf r r i f I'� h <br /> ne .es L,L,C PHONE `i/ j-20 [y_I <br /> r - <br /> OWNER ADDRESS / A l{Nr, 1 J it,o O(I D( I y Q ___ CITY/STATE/ZIP /-"_�4 ec el i `i1 7 <br /> CONTRACTOR I�1� t I I I U_I #-I'/ I)h j�_ -I( ._ _. _ ,r/�PHONE S 2-2- m Z T/ <br /> CONTRACTOR ADDRESS I (-Cr �/be /I d CITY/STATElZIP�i l+ / -es o <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATF21P <br /> LICENSE X C-57 C-61 D-09 Other NUMBER rLrc'�> L EXPIRATION DATE. <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE i Dornestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> II different from Owner: Water System Name Contact Name or Phone Tdum r _ <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bonng(s) r of hnnngs Geotechnical a of borings <br /> Out-01-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> Now Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method kMud Rotary Air Rotary huger Cable Tool Push Point Other <br /> Proposed Well Depth__36O __ft Excavation `c' in diameter Open Bottom k Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor sing Depth It <br /> Well Casing Diameter 12- in Thickness/Gauge/ASTM Sched )-0j Steel Xastic Stainless Steel Other_ L <br /> Grout Seal Depth ,/L• ft Neat Cement(94 Ib bag/5-10 gal water) VSand Cement sackmix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Zumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller \Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Sot 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)`953-76977 <br /> SIGNED �>� �J TITLE r I /-. . DATE <br /> CC- <br /> I i <br /> DIM <br /> - --— --- -- - 1 - <br /> C <br /> l W Q <br /> t <br /> 7 ~1 <br /> n lG� <br /> a <br /> — i- 1� - - — -- - <br /> 1 D E P A R T M ENT USE ONLY <br /> Application Accepted By - _ _._ <br /> Date �_ �� Area _.. _ Employee IDti <br /> Grout InsDer.linn Rv /�a��- J�Dato_ /���� S!'EC::: <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth . ft <br /> COMMENTS 1-L-11 IL w u fs �t 4 _ nGG �vl <br /> i1 _. �ril(� r ti I <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Wall ID>t <br /> EHO43.06 ViS� SV IN4u� i> Sr b fj{u' �Mk1 1, WELL/PUMP PERMIT <br /> 4/30/12 3�7�d �-Yr✓f ��"j/t��7 YYc i.s K..-�i <br />