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f ' <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH JORTMENT 600 EAST MAIN,TREET-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> T <br /> JOB ADDRESS V)i I S . CI e--okee AVC CITYIZIP �.. Ca I <br /> a <br /> CROSS STREET NA//U l./ L r1 . APN PARCEL SIZE LAND USE APPLICATION# m <br /> OWNER NAME C` b S 1"3 Vh0`4e-SG.I Q, PHONE <br /> OWNER ADDRESS qqg Lqke ►►nnwve CITY/STATE/ZIP T 96 I&M• A <br /> N <br /> 1 g 6 Z 7 <br /> CONTRACTOR J Lyou je <br /> nPHONE 901 9 7 2 .-75-2,/ <br /> CONTRACTOR ADDRESS S q S L ti CITY/STATE/ZIP 'CAV(I b C Ae 91730 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP p <br /> LICENSE ❑ C-57 ❑ C-61 ❑ D-09 /Other q Wq Z NUMBER S 0`i 4 3 1 EXPIRATION DATE p '3 I - " <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization n <br /> ❑ Public Water System U <br /> If different from Owner: er ys em NaFne Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/ModificationryOther—ALcj j OoNstr j-Jg. too 66r,..J,4 <br /> Li Monitoring Well(s)Not,,e #of wells 11 SoilBoring(s) N d nr e #of orings ❑ Geotechnical #of bori gs /1 <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair �) <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary E. Auger ❑ Cable Tool ❑ Push Point Other t LQ rJew (D0 rud;o'U 4 0 IRA d-;N� <br /> Proposed Well Depth ft Excavation in diameter 11 Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ElSteel E:, Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth It ❑ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other _ <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Acs !! rator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other At n 1hftr'.y1AaejifolgT <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft hick v in Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACGrIPDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY RE(KUIRED 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209) 953-7697 <br /> SIGNED—Zi TITLE S��trViS/J a/ DATE <br /> 1(, <br /> S <br /> L <br /> H TH DE <br /> WILL DEPARTMENT USE ONLY <br /> Application Accepted B Date Area Employee ID# 2Z- <br /> Grout <br /> ZGrout Inspection By Date ❑ iPWALhVell Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS� (9?2—0 re's I <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 2 M 4,-F-1� 12.7,60 C/ - <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 6/26/09 <br />