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WELUPUMP PERMIT <br /> SAN JOADUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE • STOCKTON CA 95205 - (209) 469x420 <br /> NON =REFUNDABLE PERMIT CALL 209 953-7`697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1953 R . 'To Km CoIVI} y ( 7. CITYmP _ Lad\ 11 CA `{ 5 2qo � <br /> CROSS STREET.7Umr\CVN % 061t ?Nv . AF N V F� 50 o(V? PARCEL SIZE "( o j 004 LAND USE APPLICATION 9 <br /> OWNER NAMEC. IG tie (ip) r + PHONE _,� 5 `' 000 °i <br /> OWNER ADDRESS ` I� `� *� \I � W ` r 1 [.�QC.( (� CrrYISTATE/ZIP LI..n bfn ,, C �7I 5 36.. <br /> CONTRACTOR V q 1 I 'C Y '('' t 1 , 1 - t PHONE 30 / <br /> CONTRACTOR ADDRESS P ' • �X 4 a CRY/STATE/ZIP Goa n)ir r c A °� 5 ( 3 a <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE)ZIP <br /> LICENSE C-57 Xi C-61 D-09 Other NUMBER EXPIRATION DAT! <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township . Range SectioD <br /> INTENDED USE )� DomestidPrivate _ Irrigation/Agricultural 0 Industrial Water Quality Monitoring = Soil Sampling/Characterizallon <br /> Public Water System <br /> Irdlllerenl from Owncr. etY3 em eme o 0 oma or ne um r <br /> TYPE OF WORK X New Weil x Replacement Web Well AlteralionlModification C Other <br /> Monitoring Wells) # of wells _ Soil Boring(s) sorb°" a' C Geotechnical Mor borings <br /> r Out-Of-Service Well — Out-Of-Service Well Renewal Cross-Connecllon Repair <br /> New Pum C Pump Replacement = Pump Repair = Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method )C Mud Rotary r Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 350 ft Excavation a to In diameter I Open Bottom 7C Gravel PaddGravei Size If 4 _ In diameter <br /> 0 Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter CCL in Thidmess/Gauge/ASTM Sched CI a OQ 0 Steel K. Plastic :) Stainless Steel r_ Other. <br /> Grout Seal Depth 100 ft _ Neat Cement (94 10 bag/5-i0 gal water) (Sand Cement C, 3 sack mix/7 gal water <br /> Bentonite (20% solids) �. Other <br /> Grout Placement Method umped . Free Fall _ Other LI Retardant / Accelerator (name) <br /> PED STAL Installed By X Driller L Pump Contractor i Other <br /> Concrete Pedestal nDimenstons: Width s it Length Z_ R Thick in ^ Christy Box _ Stove Pipe <br /> PuMP Submersible — Turbine r- Other HP Pump Set.22 5R Standing Water Level <br /> it <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 /> MIN UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9534697 <br /> SIGNED TITLE_ `r r C— f rC S l Q t1 DATE <br /> T G <br /> � S nr <br /> G t <br /> 02016 <br /> t ��ry <br /> At COUNTv <br /> 010h 'nH-r„E,V,, <br /> DEPARTMENT USE ONLY U n <br /> G � <br /> Application Accepted By Date � Are t' Lk Employee ID# :5w o" <br /> Grout Inspection Bll c l T Date 2 SPECIAL WeII Permit <br /> Pump Inspection By t Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#1 Amount Date Permit/ Invoice # Well 10# <br /> Codes Info B Ca Remitted Service Request 4 <br /> q , G 3� r ' 11 <br /> IA � 3 (> 't) _ 0 7 tr 2 <br /> ARL Pt <br /> E8043-06 /7 <br /> 4130112 _ [ /1�� � / l ' 'NELL /PUNP PEfikrr <br /> / ' ii if <br />