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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 /> JOB ADDRESS A21 W. �--S Ca t U?•^ &116�,k r _ CITY/ZIP / 3,C m <br /> D <br /> CROSS STREET APN 6 1 3- qt)- ' PARCEL SIZE�.� LAND USE APPLICATION# <br /> m <br /> T � i <br /> OWNER NAME J�p�� y Z (R G� /J PHONE - <br /> OWNER ADDRESS I Z' SQ.91�O 1\ CITY/STATE/ZIP P �n d-,e h f 91 fzf � <br /> CONTRACTOR 4 s el ( �J ( \ (V�t F C• PHONE 5.22-- `j`9 7—�/�7 /` <br /> CONTRACTOR ADDRESS wqe r S I`4 CITY/STATE/ZIP m 0 d4 S r o: r 1 / 5✓ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE �-57 C 61 D-09 Other NUMBER EXPIRATION DATE 7 �3C) �J <br /> GEOGRAPHICAL INFORMATION: COO nates X Y Township Range Section <br /> INTENDED USE L Domestic/Private rrigation/Agricultural L IndustI ni �i tih aracterization <br /> F1 Public Water System nIj <br /> If different from Owner: Water System Narffe o •■ v e • act%one Or RwrOmOMmber <br /> u <br /> TYPE OF WORK <New Well Replacement Well ❑ Well Alteratiolarjiultifflay auQ� t <br /> #o lb �t�, #of borings <br /> Monitoring Well(s) #of wells 17 Soil eoring(s)��} f1 �,Pleted otnt "v��i- <br /> Out Of-Service Well ❑ Out Of-ServicejW l Reraejal �onctipn die it <br /> New Pum Pum Replacement Pum Re air oy `et�1�vnmar aa- AI('as�r �t� �On <br /> WELL CONSTRUCTION <br /> Drilling Method NMud RoNar Air Rotary Auger Cable Tool Push Point ONr <br /> Proposed Well Depth Q ft Excavation y t--/ in diameter 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 e"'- ' U ?(Steel Plastic ❑ Stainless Steel Other <br /> Grout Seal Depth S O ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement f�' sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method->."Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller XPump Contractor Other <br /> Concrete Pedestal 'Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine 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 /> M7',L� TITLE <br /> UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209)953-7697 <br /> SIGNED ?>^ //e DATE //— /6_. � L. <br /> y "V <br /> Am <br /> IV <br /> AA 117AI'lAt <br /> � <br /> N <br /> wt <br /> .J 0l4314011 <br /> UPARTMENT USE ONLY <br /> Application Accepted ByIftte 3s Area �A� Employee ID# <br /> Grout Inspection By Dat '` ❑ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By � ft may CtVeapire ��) C}uConstructed Well Depth ft <br /> COMMENTS I .l7i.� emg complete or IriSpeC_Y,. <br /> htiJzz 4rS—mneF?tal Health Diyi.lop <br /> PE SC Received Chec Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />