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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> t NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> I Ddu S/ m <br /> JOB ADDRESS 7 . f e _ CITY/ZIP D <br /> !-� ' O <br /> CROSS STREET M! { 1.11t/.O, �e '4 APN w,�0 006­ PARCEL SIZE /�• D LAND USE APPLICATION m <br /> OWNER NAME ��1�_I ` _.hsN ✓Vq►v ... PHON �__/ ✓__ N <br /> `� 1Iy t Qill�c C <br /> OWNER ADDRESS & W E'erI A V 1 ' 14 'C CITY/STATE/ZIP <br /> 1. <br /> T" AeY <br /> CONTRACTOR �'A �u ��P�L IIlr PHONE C. <br /> CONTRACTOR ADDRESS _��Dm .'I CITY/STATE/ZIP— <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE A-,e-57 1C-61 i D-09 ( Other NUMBER s/ EXPIRATION DATE �J <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section___ <br /> INTENDED USE Domestic/Private C: Irrigation/Agricultural f.) Industrial ;.1 Water Quality Monitoring D Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Name Contact ame or Phone Number <br /> TYPE OF WORK ( ew Well 11 Replacement Well ❑ Well Alteration/Modification ❑ Other. 4d <br /> iJ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings C Geotechnical Ap{ #of borin <br /> 17 <br /> New PfumervicelWPll Li um Replacement ❑ Pump Reeaif e Well Renewal fu Raise Well lCaslnn Repair N� Th <br /> gMFNTq�Ty <br /> WELL CONSTRUCTION <br /> S� Nr <br /> Drilling Method 0< d Rotary Air Rotary i 1 Auger u Cable Tool Push Point 11 Other <br /> Proposed Well Depth_.-� ft Excavation _ IjQk�Z in diameter ❑ Open Bottom r Gravel Pack/Gravel Size_in diameter <br /> I Conductor Casing_ in diameter / Conductor Casing Depthft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched <2 1 '] Steel L lastic Stainless Steel L-j Other_ <br /> Grout Seal Depth /Oo ft Neat Cement(94 Ib bag/5-f0 gal water) G Sand Cement sack mix/7 gal water <br /> bentonite(20%solids) 'I Other <br /> Grout Placement Method 1.) Pumped Free Fall i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By [:] Driller ump Contractor J Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box r' Stove Pipe <br /> PUMP I' Submersible!, Turbine I Other HP Pump Set 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 MPENSATION LAWS. <br /> i4MI� <br /> NCE NOTICE REQUIRED FOR,'INSPECTIONS - EASE CALL (209)953-7697 <br /> SIGNEDTITLE&UM DATE �—�� 17 <br /> i <br /> �T <br /> ' I <br /> J <br /> DE ' AR 'rMENT '' S != ONLY r <br /> / Application Accepted by__ Date t Area 7 Employee ID# <br /> Grout Inspection By Date Y ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soi!Boring 1 spection By Date Constructed Well Depth <br /> COMM N I S t 1AJrrt/ tMAJ AY <br /> PE Sc Received Ch Amount Date Permit! Invoice# Well ID# <br /> Codes Info By_ Cash Remitted Service Request# <br /> f_A <br /> 1HD 43-06 <br /> 4'30/12 �� �O� WELI./PUMP PERMIT <br />