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WELUPUMP PERMIT <br /> SAN JOAMIN COUNTY ENYIAONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jog ADDRESS 2 N u� �A - q93 Lots � <br /> CROSS STREET D <br /> 1 �t[�t J�t�APN V PARCEL SIZE <br /> -75 <br /> t ANO USE APPLICATION# p <br /> OWNER NAME )NII(I� CIII 1 I "\I�V! PHH�{O\NtE��2-0q <br /> OWNER ADDRESS _9 (�yAI� I 1� r CITY/STATE171PnA <br /> �[UI V Cha -Ir'!JIUIY <br /> CONTRACTOR III[ S IIS /Y'III'IA INC' PHONE <br /> n All) <br /> � <br /> CONTRACTOR ADDRESS (I r� <br /> q I V QRy7��1 a CITY/STATEgJp t(J, J� "1 C;:K7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 0 C-61 0 D-09 C Olhef NUMBER�JTW-7, ExPIRAT1oN DATE <br /> DomrsTlc WELL SAMPLING:t�General Mineral/Coliform Bacteria(4391)Dibromochloropropane(4392)G Arsenic(4393) <br /> INTENDED USE �DOmestic/Private D Inigatlon/Agriculturel ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> C ublic Water System <br /> It ditmt from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well n Well Alteration/Modification D Other <br /> u Monitoring Well(s) #of wells n Soil Bonng(s) *of boring. C Geotechnical-8 of boring, <br /> C Out-Of-Service Well ❑Out-Of-Service Well Renewal D Cross-Connection Repair <br /> C New Pump ❑Pump Replacement D Pump Repair D Raise Well Casing <br /> WELL COH3TRUCTION <br /> Drilling Method.XMud Ro D Air Rotary ❑Auger O Cable Tool ❑Push Point C Other <br /> Proposed Well Depth2 O ft Excavation�I"in diameter D Open Bottom *ravel Pack/Gravel Size� in diameter <br /> El Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter. In Thickness/Gauge/ASTM Schad'n0 ❑Steel laslic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft D Neat Cement(94 Ib ba9/5-10 gal water) C Sand Cement sack mix/7 gal water <br /> *entonde(20%solids) ❑Other <br /> Grout Placement Method)dumped G Free Fall D Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal DDimenslons:Width R Length ft Thick in D Christy Box D Stove Pipe <br /> PUMP D Submersible Turbine D 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 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> UR ADVANCE NOTICE REQUIRED F R INSPECTIONS-PLEASE CALL(209()99153--77697 <br /> SIGNED TITLE TITLE I DATE ll 1' J• L <br /> EvNT <br /> FD <br /> 0 <br /> 4 2010 <br /> H ENTq�TY <br /> RTry)ENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted Byi�L - Data 7 twiI - <br /> Area ` <� Employee IDS <br /> Grout Inspection By Date 7' ���� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth h <br /> COMMENTS <br /> PE SC Received Checks! Amount Permit/ <br /> Codes Into h Remitted Date rusts R oast 0 Invoice# Well IDS <br /> a� 7 , <br /> L 3` saw J ; <br /> ?c7 7 7 <br /> EMD 43-D8 &Dina <br /> WELL[PUMP PERMIT <br />