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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 /> ti S�'� <br /> JOB ADDRESS � // � �N Q N�/r 4�r11/ c�TvmP D <br /> CROSS STREET A r k4 I/ APN/9 �J y 00 2 PARCEL SVE��LAND USE APPLICATION#Ifa <br /> OWNER NAME �GG I�j ��2�/ J41Q CL��!^L� PHONE y <br /> OWNER ADDRESS 7l.7th .�. LCYrs�'Ia�A 7/ QTY/STATEZPah&;P.1 <br /> CONTRACTOR e-eer ��iare EM✓�. �'MG TPHONE�'• /22 S'G5'429�y3 <br /> CONTRACTOR ADDRESS,2 '/57 eejte—vq M Ave ,a,Z4Y7 CITY/STATHZIP <br /> SUBCONTRACTOR / PHONE <br /> SUBCONTRACTOR RESS CITY/STAMIZIP�aQ 1 /� �S z� <br /> LICENSE _C- L C-61 u D-09 u Other NUMBER 0(O EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE DomesticfPrivate I I Irrigation/Agricultural I Industrial Water Quality Monitoring ASoil Sampling/Characterization <br /> Public Water System <br /> If ddferent from Ovner: Water 5Wem Nam contact Name or Rhme NuMber <br /> TYPE OF WORK New Well Replacement Well Well Afteration/Mod fication Other <br /> S <br /> =Monitoring Well(s) #dwells �SoilBoring(s) i of borings CGedechnical of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> -New Pum -Pump Replacement -Pump Repair -Raise Well Casing <br /> WELL CONSTRUCTION (/ <br /> Drilling Method Mud Rotary Air Rotary i i Auger i Cable Tod Push Point i i Other <br /> Proposed Well Depth It Excavation in diameter ❑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 I I Slee) Plastic I Stainless Steel i i Other <br /> Grout Seal Depth a ft )(Neat Cement(941b bagl5-10 gal water) =Sand Cement sack mbr7 gal water <br /> =Bentonite(20%solids) 7 Other <br /> Grout Placement Method :1 Pumped Y.Fall C Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 7 Pump Contractor ❑ Other <br /> Concrete Pedestal I(Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP _Submersibleu Turbine -i Other HP Pump Set ft Standing Water Level ft <br /> IN <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 /> MINI UM 24 H UR ADVANCENOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE C.�/'J'L/Sf'/�7ZT +� DATE <br /> 221 <br /> SIE L <br /> DEPARTMENT U ON <br /> C4V71 <br /> Ley 4; <br /> Application Accepted By Date /IL <br /> ArmEmployee ID# C <br /> Grout Inspection By Date fl SPECIAL Lk.li Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Soil Boring Inspection By Date Consttrruuctedd Well Depth ft <br /> COMMENTSV�0 c ye$ TV 2A <br /> PE Sc Received Check#1 Amount Date Permit( Invoice# Well IDN <br /> Codes Info Rem' Service Request# <br /> EH D 1306 WELL/PUMP PERMIT <br /> 4130/12 � 1 ` <br />