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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 INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS ,�/ CITY/ZIP D <br /> CROSS STREET_ /L!//��LW7� Gr AVIVL' f�� o <br /> 3t_ PARCEL SIZE ID/� LAND USE APPLICATION <br /> OWNER NAME PHONES <br /> OWNER ADDRESS CITY/STATE/ZIP- !CA <br /> CONTRACTOR O �S t �— PHONEC !9r9/�/_ 5z%0 <br /> CONTRACTOR ADDRESS ! `'�"�L� CITY/STATE2IP /–�/ <br /> i <br /> SUBCONTRACTOR � PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP__ c <br /> LICENSE -57 -61 i D-09 ❑ Other NUMBER �1EXPIRATION DATE l , <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township .__ Range Section <br /> INTENDED USE omestic/Private 'I Irrigation/Agricul iMIT, arQ.uati YIV i�ng' oil Sampling/Characterization <br /> Public Water SystemP rr fr: 6`� i <br /> If different from Owner: at a >: Name or Phone Number <br /> TYPE OF WORK New Well i I Replacement Well 4-xaguleiia"motupiredmiltdAnut <br /> Monitoring Well(s) #of wells fit:ty5`+1 6 }�� �� ` f1 Geotechnical_ of borings <br /> Out-Of-Service Well O/u Of-Service Well a al Gross-Connection Repair <br /> ,AAew Pum Pum Replacement LDVU w1 hnooptar UL.i Raise Well-Casing <br /> WELL CONSTRUCTION <br /> Drilling Method/>VLid Rotary„ Air Rotary i Auger ❑ Cable Tool Push Point Other <br /> Proposed Well Depth_c:;?70_ft Excavation Ax in diameter i I Open Bottom ravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In I Thickness/Gauge/ASTM Sched (::A_AD I, Steel�i lastic ❑ Stainless Steel Other <br /> Grout Seal Depth ft ir� Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mixf7 gal water <br /> ,JdBentonite(20%solids) L Other <br /> Grout Placement Method i I Pumped Free Fall Other i Retardant/Accelerator(name) <br /> PEDESTAL Installed By I Driller ump Contractor I Other <br /> Concrete Pedestal imensions:Width ft Length ft Thick s in Christy Box Stove Pipe <br /> PUMP Submersible i Turbine Other HP Pump Set oejnO ft Standing Water Level <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 /> MINI �r Q�{–) NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95 76q7 <br /> SIGNED �'4 ` �� TITLE__ DATE <br /> f <br /> 1 141 <br /> t <br /> L <br /> r <br /> L J <br /> INC U <br /> 01MENTA <br /> DEPARTMENT USE ONLY <br /> Application Accepted By'4 A o&I ` t Date l �e� Area Doi Employee <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By _ Date 1 Constructed Well Depth <br /> COMMENTS 6C LA-4 u"O.fi S'e-ct, :�0 LU 4-rei+t S Nt Pit .1!!t <br /> PE SC Received Chec Amount Date Permitt Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Re uest# <br /> 3 t �f�3 3y <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />