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19 <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENMRONMENTALH DEPARTMENT 600 EAST MAIN$TRE. STOCKTON CA 95202-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �t m <br /> JOB ADDRESS `�'` CRY21P D <br /> O <br /> CROSS STREET 41�1'N �-IC _ y APNe� -i (� ARCEL SIZE LAND USE APPLICATION# <br /> in <br /> OWNERNAME PHONE N <br /> OWNER ADDRESS �5 ✓ �na I�jR WIYVIQ/L c/!gw CITY/STATE/LP <br /> CONTRACTOR �C.�2S .LNC- a' PHO�NE�y7`,9/6 •`_ ` �p. <br /> CONTRACTOR ADDRESS �-( L)&!A= (fa-e 'K �/Z CRY/STATEMP 'TCA"-vrc-N/tp �, p <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATEMP <br /> -'� /7 9031-fG a <br /> n n (1 pp w NSE I I C-57 C-61 IID-09 Other C.-�rt i� NUMBER EXPIRATON DATEV/1 <br /> 3� g6 1 0 <br /> u N =61DGRAPHICAL INFORMATION: COordinateS X Y Township_ Range Section <br /> WENDED USE Domestic/Private ❑Irrigation/Agricultural C Industrial 7 Water Quality Monitoring 7 Soil Sampling/Characterization R <br /> ry [) 7 Public Water System \' <br /> If different from Omer: Water System Name comaCt Name or Phone Number \\ <br /> y- F WORK :1 New Well ❑Replacement Well C Well Alteration/Modification ther <br /> u <br /> Monitoring Well(s) #of wells ❑Soil Boring #of borings ❑ <br /> Boring(s) Geotechnical #of borings <br /> 7 Out-Of-Service Well C Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> 0 7 New Pum 7 Pum Replacement E Pum Repair <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary 7 Air Rotary C Auger ❑Cable Tool ❑Push Point X Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter '? <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel C Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> 7 Bentonite(20%solids) :1 Other <br /> Grout Placement Method a Pumped u Free Fall u Other -1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> 7 Concrete Pedestal Dimensions:Width It Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP D Submersible Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> 1N <br /> 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 /> INI M 24 HO ADVANCE NOTICE REQUIRED FOR INSPECTIONS p <br /> SIGNED TITLE - DATE B v <br /> if -11 <br /> E <br /> DEP RT ENT US NLY C <br /> �— r <br /> Application Accepted Date Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Perrnit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By 1 Date 5 l Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B as .Remitted Service Request# <br /> `fit I I S, 0 .5400yllo <br /> EHD 43-08 WELL-PUMP PERMIT <br /> 9128107 <br />