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6�1� rv.vf <br />r , <br />�( 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 INSPECTIONM EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS tCt �G �T /� /] CITY/ZIP [j�2. <br />CROSS STR EETQCLC rG1.✓1t0.� QQiI A•P�N �1 L�l`.)IG,O (-, "1 f �1PARCEL SIZE .�O �a LAND USE APPLICATION # r <br />OWNER NAME l�R KY7�C—//IUI-H/W JA&1fJ'r0jZS LLQ- a.ONE 1 . AA/ —,jta Ci <br />OWNER ADDRESS .'J X�) S i�1010.s HIVCi i • S�e, Z '5U( ' V'r CITY/.9TA7TE/ZIP Vl� �Q t )111 e L -.h <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS CITY/$TATE/zIP6 ' 'J Q _ _ ,. _. 0 d pts <br />69bCONTRACTOR H�XkS iCIQ �3�t��rP./r 4�n .I Qrl�ll /1 PHONE �C� —8(S -.57, <br />=XCONTRACTOR ADDRESS CCIRY/STATE/ up Tj/t'it c , CA 9-5342 <br />LICENSE KC -57 7 C-61 7 D-09 7 Other NUMBERat�623,C, ExPtRATIGND ETA/��/!a <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE 7 Domestic/Pdvate 7 Irrigation/Agricultural 7 Industrial 7 Water Quality Monitoring 5rsoil Sampling/Characterization <br />7 Public Water System <br />If different from Owner: water SyStern Name on a ame or Phone Number <br />TYPE OF WORK 7 New Well -1 Replacement Well = Well Alteration/Modification :I Other <br />7 MonitoringWells #of wells = SoilBorin s #ofbodngs #ofbodngs <br />O 9O Geotechnical <br />7 Out -Of -Service Well = Out -Of -Service Well Renewal 3 Cross -Connection Repair <br />Drilling Method -1 Mud Rotary 7 Air Rotary ,Auger 3 Cable Tool -j Push Point 7 Other <br />Proposed Well Depth k7—IS' ft Excavation �� in diameter 7 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 :1 Steel -j Plastic :) Stainless Steel I Other <br />Grout Seal Depthh— Q; ft 7 Neat Cement (94 lb bao-10 gal water) 7 Sand Cement sack mix/7 gal water <br />R'Bentonite (20% solids) 7 Other <br />Grout Placement Method I Pumped A Free Fall :1 Other :1 Retardant / Accelerator (name) <br />PEDESTAL Installed By 7 Driller 7 Pump Contractor 7 Other <br />7 Concrete Pedestal -1Dimensions: Width ft Length ft Thick in :1 Christy Box 7 Stove Pipe <br />PUMP 7 Submersible:] Turbine 7 Other HP Pump Set ft Standing Water Level ft <br />1 HEREBY CERTIFY THAT 1 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 />71!OUR`�%DV}/g�NCE OTIC REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED (/\.1'/ � TITLE OWAMe DATE 311 S// <br />1 VE® <br />6 2011 <br />N <br />VMFA,UICD,.UN1Y <br />PAIRTMENT tjSEjONLY <br />Application Accepted B r Date ((2 Q Area Employee ID# �4 � <br />Grout Inspection By Date ❑ PECIAL Well Permit <br />Pump <br />Soil Boring <br />COMMENTS] <br />Date <br />❑ WAIVER Received <br />Constructed Well Death <br />PE SC Received ChacW Amount <br />Codes Info B Remitted <br />Date Permit/ Invoice# WeIIID# <br />Service Request # <br />CFO�U . <br />3 I� d7 1 X00-co9(A <br />EHD 43A6 WELL /PUMP PERMIT <br />4130/12 <br />