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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 /> -108 ADDRESS J E5LAI 1/ CITY21P� 4lyYP q1/3 to m <br /> D <br /> I <br /> CROSS STREET G�j A `�__PN � ARCEL SIZE LAND USE APPLICATION# <br /> 7 m <br /> OWNER NAME t V/(//r L_ PHONE o,7 - ?� aL 1- r <br /> OWNER ADDRESS y�a�� ��d�- � CITY/STATE/ZIP <br /> CONTRACTOR � ly/� ���/J�S/ %��yI�GG�,LLf�1 PHHONEn ? If <br /> CONTRACTOR ADDRESS /�J /J °f�- / f 9 _ CITY/STATE2IP 1t. )z//C/- Qby` <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE <_t-57 C-61 D-09 Other NUMBER 2,-2 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X__ Y _ Township Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural ❑ Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> I Public Water System_____ _ <br /> If different from Owner: Water ystem ame Contad Name�or hone Num <br /> TYPE OF WORK New Well I Replacement Well ❑ Well Alteration/Modification I Other <br /> !I MonitoringWells #of wells ❑ Soil Boring(s)s n of borings <br /> O -- gO __ Geotechnical <br /> Qut-Of-Service Well 11 Out-Of-Service Well Renewal ❑ Cross-Connection Repair y `F <br /> New Pump ❑ Pump Replacement Cl Pump Repair 17 Raise Well Casing <br /> WELL CONSTRUCTIONNJ©AQUI <br /> Drilling Method>cMud Rotary 17 Air Rotary Auger P Cable Tool Push Point Li Other k eNV/RO N COU <br /> Proposed Well Depth .moi`� ft Excavation 1�� in diameter Open Bottom Gravel Pack/Gravel Size cpAf diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft / <br /> Well Casing Diameter 3 in Thickness/Gauge/ASTM Sched- Lam' -1 Steel i<Plastic Stainless Steel Other <br /> Grout Seal Depth fc) ft Neat Cement(94 lb bag/5-10 gal water) ySand Cement�l sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Metho44 Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By *--Driller Pump Contractor Other_ <br /> Concrete Pedestal Dimensions:Width ft Length_ ft Thick in Christy Box Stove Pipe <br /> PUMP �SUbmersible Turbine 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 COMPENSATION LAWS. <br /> MINIMU 24 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED TITLE_ " ' DATE <br /> L <br /> -. b` <br /> E ARTMENT U tJ, NY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date 2 ❑ SPECIAL Well Permit <br /> Pump Inspection By + Nc jS(o �(1D�t .` Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth sa ft <br /> COMMENTS i Vk4a CAky _ <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cas Remitted Service Request# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />