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WELUPUMP PERMIT <br /> 'SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS "? / ` a �L S I �1 1� -- — CITY/ZIP l�l L �L m <br /> t l � (` y,` ) o <br /> CROSS STREET LU(�S+ C� 1 10�-%- )�APN ���e2—S/ PARCEL SIZE LAND USE APPLICATION ft m <br /> M <br /> OWNER NAME -- --- PHONE � <br /> OWNER ADDRESS WS � L b b 1- I' �/ ��� CITY/STATE/ZIP <br /> CONTRACTOR /Y l���/�( t S 5V4 l t ti�ck4 7 PHONe--3—,?0—/�Z2 <br /> CONTRACTOR ADDRESS 4 b�e N� J�C?r _ CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBERJ �e— <br /> EXPIRATION DAT F�I <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private -j<rrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well I Well Alteration/Modification L Other <br /> F <br /> G Monitoring Well(s) #of wells I Soil BoringN of borings of t c Ings Cs) Geotechnical__ <br /> - <br /> CI Out-Of-Service Well I Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump Pump Replacement i Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION _� E•-1 <br /> .+r�aiae+o T(a) i.- <br /> Drilling Method X�(vlud Rotary Air Rotary Auger Cable Tool ❑ Push Point Other <br /> Proposed Well Dept ft Excavation _.Z� in diameter TI Open Bottom ravel Pack/Gravel Size �i, � 7-dimeter <br /> i Conductor Casing in diameter / Conductor Casing Depth ft i r <br /> Well Casing Diameter.�� in Thickness/Gauge/ASTM Sched 11 (? Steel Mastic S'^^Iocc steel Other Cl <br /> Grout Seal Depth,Z'V ft Neat Cement(94 Ib bag/5-10 gal water) 1 Sand Cement— saa&i)l gi ljwater <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped -i Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller '?�ump Contractor Other =- r- <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy x 155 p Pim <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing r Leve' 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br /> SIGNED fL •4w+�� TITLE t,4 — ;,r ATE' <br /> 1i ii I <br /> r <br /> Lx <br /> t <br /> �• f i u L iT Zu <br /> rOlf <br /> �` Ci L ri lil <br /> .ter <br /> y (_7 17-1. ,. , ., <br /> t � <br /> 71 <br /> 11 JI <br /> O N <br /> ELE LT <br /> i <br /> DEPARTM ENT USE O N L Y <br /> Application Accepted By Date _1 Area ` Employee ID# �` °�v,> <br /> i <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received a Amount Date PermiU Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> 1i q L1 4114/1 5RtV71 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />