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t, <br />W1 <br />6 70 1t �S <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 £'6S EAS i HAZFLTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />/r �_. <br />�-j tHome <br />aJ� <br />/ � ✓-- <br />JOB ADDRESS / 'Stl`/10 <br />CIT'f/ZIP <br />Date <br />Permit/ <br />Service Request # <br />l <br />CROSS STREET lKa _`0`0 A.) /�_ APN � 7 -z0 7y 6 �i _ PARCEL SIZE ���_��AND USE APPLICATION # <br />Well ID# <br />OWNER NAME ✓ �k'IN J�� _ <br />_ __ PHONE\ 4) <br />900 <br />% <br />L/ <br />OWNER ADDRESS G\ <br />CITY/STATE/ZIP i ` U/ A' <br />sgDo-1911-7 <br />v <br />CONTRACTOR I -C ka- / •+`�/ ,7 4A 'r (�^ oF,(1t V. / �%l� <br />_—_ PHONE � <br />7"V 1 :!5 - <br />CONTRACTOR ADDRESS v14oo/ yr rr ' �^' Z` <br />CITY/STATE/ZIP Z_l" - ,'r; O?f <br />SUBCONTRACTOR <br />PHONE ZIA <br />SUBCONTRACTOR ADDRESS ej;Ki_ CITY/STATE/ZIP- <br />LICENSE _kt C <br />-57 `1 C-61 D-09 l Other NUMBER ! 597? 7 - EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X _ Y __, Township _ Range Section <br />INTENDED USE LJ Domestic/Private Irrigation/Agricultural [I Industrial , i Water Quality Monitoring L. Soil Sampling/Characterization <br />Public Water System _ <br />If different from Owner: Water System Name fact Name or Phone Number <br />TYPE OF WORK A New Well I ' Replacement Well 0 Well Alteration/Modification Cl Other <br />❑ MonitoringWells # of wells ❑ Soil Boring(s) s # of borings # of borings <br />O gO � Geotechnical <br />0 Out -Of -Service Well ❑ Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />❑ New Pum _. Pump Replacement 0 Purno Re air F1 Raise Well Casin <br />WELL CONSTRUCTION <br />Drilling MethodXMud Rotary I Air Rotary -I Auger ❑ Cable Tool i 1 Push Point Other <br />Proposed Well Depth 3)0 ft Excavation ',"Jln diameter ❑ Open Bottom XGravel Pack/Gravel Size S in diameter <br />11 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter ! in Thickness/Gauge/ASTM Sched 2 'i Steel ,Plastic " Stainless Steel Other <br />Grout Seal Depth . j, ft l' Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />I Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fail Other Retardant / Accelerator (name) <br />PEDESTAL Installed By CI Driller XPump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in -1 Christy Box 7 Stove Pipe <br />PUMP i Submersible ! Turbine 1 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 />MI I M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95/3-7697 <br />SIGNED .�^, / - {- 7` ' \ TITLE l' 'V11v DATE <br />Grout Inspection By ___,__ Date <br />Pump Inspection By Date <br />Soil Boring I spection By _ Date <br />COMMENTS -5f IX tO G'LAY^,' <br />T <br />m <br />D <br />0 <br />0 <br />M <br />m <br />in <br />49 <br />Area Employee ID#GAS <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />6 <br />I <br />if <br />i <br />sgDo-1911-7 <br />EHD 43-06 <br />4/30/12 <br />WELL/PUMP PERMIT <br />