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ir1 i/ ck1 -P / <br /> WELUPUMP PERMIT <br /> SAN JOAOIAN COUNTY ENNRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-U20 <br /> NON-REFUNDABLE PERMIT CALL 209 963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDREss 11953 F—.-TQ K o,y Go k o Y R n• crTYmP Lod� ) C A 9 5 2 4 o m <br /> _ D <br /> CROSS STREET�^�((\��li-�TV1'►t~ 11�V.J1 AP1N eL�i1��0 Da� PARCEL SIZE�-'A LAND USE APCATIONm <br /> OWNER NAME&IG L■1 e--r S TOnUnC'A a r A- PHONE <br /> �yJ <br /> OWNER ADDRESS �� { 1 `1 (�pW `' I [ {(/ CrTYISTATE/ZIP LIEIft"fl I QCAV qJS a 3 <br /> CONTRACTOR �I O'N- 7 T-)�('1�`1(1 pl PHO1HE 3W 9/�Of / + 9 <br /> CONTRACTOR ADDRESS l O • 11 O�C �i CrTY/STATE/Z1P Gq 1A-r CA g S0 a <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRYISTATEIZIP <br /> LICENSE )CC-57 ?<C-61 _D-09 Other NUMBER ExPmAnoivDATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE )WornestirJPrivate C Inigation/Agricullural =industrial C Water Quality Monitoring C Soil Sampling/Characterization <br /> "t Public Water System <br /> ndiRorcntk=OWnaC water System Name contact f4ame,or Phone Numocr <br /> TYPE OF WORK X New Well )(Replacement Well E Weil Alteration/Modification Other <br /> Monitoring Well(s) 3 of wells Soil Boring(s) s of borings =Geotechnical A or borings <br /> r-,Out-Of-Service Well - Out-Of-Service Well Renewal -Cross-Connection Repair <br /> New Pum C Pum Replacement Pum Repair -Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method?'r Mud Rotary -Air Rotary -Auger - Cable Tool r Push Point -- Other <br /> Proposed Well Depth 350 ft Excavation k2 111 in diameter Open Bottom ',*X Gravel PaddGravel Size 1/4 _ in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched C)a O A =Steel �CPlestk Stainless Steel Other <br /> Grout Seal Depth l_�ft Z Neat Cement(94 Ib bagl5-10 gal water Sand Cement kj .3 sack mixl7 gal water <br /> i Bentonite(20%solids) L Other <br /> Grout Placement Method XPumped Free Fall c Other :Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller L Pump Contractor -i Other <br /> Concrete Pedestal;IDimensions:Width S ft Length_Z ft Thick in ChristyBox r Stove Pipe <br /> PUMP Submersible-Turbine r Other HP Pump Set it 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IM COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE `r r C L f rC-S d e t'1 DATE `1 <br /> G �;I- <br /> VSel I <br /> � AVE U <br /> y <br /> 2 Q 2016 <br /> ,` F UIPIC��h�.rt <br /> 0 NAF17,y;E11"� <br /> -777 <br /> TTTT <br /> DEPARTMENT USE ONLY <br /> Application Accepted ey + Date �Z�ZJ �ji Are C14, �1� Employee ID* 4:5 <br /> Grout Inspection B7�Z ! - Date ' :1 SPECIAL Well Permit <br /> Pump Inspection By Date�� 7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth it <br /> COMMENTS <br /> PE SC Received Chackti Amount Date Permit/ Invoice# Well ID# <br /> ' Codes Info B Ca Remitted Service Re uest# <br /> n 7 ' 1 E09 3 7!�5 <br /> ' Eli D 43-06 /� �)/ / i('� WELL!PUMP PERMIT <br />