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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 C1, CALL 209 953-7697 FOR INSPECTIONS ('EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS ( V I SA 10,1,q U/ Cm/LP L/ I 0 <br /> D <br /> PARCEL SMO.03 LAND USE APPLICATION#CROSS STREET APN <br /> 0 ^^ <br /> 19 qOWNER NAME O93,9 0 <br /> OWNER ADDRESS CRY/STATEZP <br /> CONTRACTORC9 <br /> PHON <br /> CONTRACTOR ADDRESS CRY/STATEZPQL�A[Q <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYYIISSTTATEZP <br /> LICENSE n G-57 'f,G-61 I7 D-09 1..1 Other NUMBER /i�T 9 �_ ExPIRATON DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE 11 Domestic/Private 0 Irrigation/Agricultural O Industrial n Water Quality Monitoring 1 Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name sena or ne u er <br /> TYPE OF WORK 0 New Well t-i Replacement Well In Well Alteration/Modification I7 Omer <br /> C Monitoring Well(s) #of wells 0 Soil Boring(s) 0 o bednpe C Geotechnlcal Sdbodn0s <br /> In Out-OfServlce Well 1.1 Out-Of-Service Well Renewal C Cross-Connection Repair <br /> C1 New Pump 0 Pump Replacement ❑Pump Re alr 0 Raise Well Casin <br /> WELL CONSTRUCTION n <br /> Drilling Method fa Mud Rotary !i Air Rotary 11 Auger P Cable Tool 'Push Point i.1. Other PA Y <br /> Proposed Well Depth ft Excavation In diameter I. Open Bottom 1:1 Gravel Pack/Gravel Size in diameter C�� <br /> 0 Conductor Casing In diameter I Conductor Casing Depth ft ` �� <br /> Well Casing Diameter_In Thlckness/Gauge/ASTM Schad :1 Steel p PlesUc :Stainless Steel C Other O <br /> Grout Seal Depth ft i l Neat Cement(94 Ib bag/S10 gal water) I i Sand Cement sack mIx/7 gal wat ' / O <br /> I",Bentonite(20%solids) 0 Other 2 <br /> Grout Placement Method n Pumped 0 Free Fall 0 Other c Retardant/Accelerator(name) AQU)N O�v <br /> PEDESTAL Installed By 17 Driller C Pump Contractor C Omer p JIN p(1N�r <br /> C Concrete Pedestal❑Dimenslons:Widen ft Length ft Thick in C Christy Box ❑Stove Pipe Q /�l <br /> PUMP Submersiblell Turbine n Other. HP Pump Se ft Standing Water Level ft EPgRrA/NT <br /> 1 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. 1 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 /> M U 24 HOUR V E N Q-2—REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95 -7 97 <br /> SIGNED TITLE OPII/ rC/Y DATE �D <br /> UP <br /> TMENT USE C/�,NLY <br /> Application Accepted By 1 mate�r—'— Area�� Employee ID# r ay N'J <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 51 O WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received hec Amount Permit/ <br /> C0423 Info B emitted Date Service Re uest# Invoice# Well IDN <br /> //z9 /o WP004017 <br /> 07 <br /> EHO 43-Oe WELL/PUMP PERMIT <br /> 4/30/12 <br /> I <br />