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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 1 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ��/'{�I//I�yLL/� L.��f CITYRIP �lL� IJ�I � � Z� �— D <br /> CROSS STREET re/7A�/t /—L�I��L� APN PARCEL SIZE LAND USE APPLICATION# m <br /> N <br /> OWNER NAME �� _ )yP�HONE,�!� /`'�/J�// �� <br /> OWNER ADDRESS J '7ci��f._� z�L�+ CITY/STATE/ZIPf/L'i C: C"f_�� / / <br /> CONTRACTORI !✓�C flC%/�� �/I�, PHONE rr'r/ �JJ 'Z 7J-7 <br /> CONTRACTOR ADDRESS " r ��Zc-f�i���G�� � CITY/STATE/ZIP�L�'r S��11�._�,%'� �- <br /> SUBCONTRACTOR _ PHONE <br /> SUBCONTRACTOR ADDRESS _ CITY/STATE/ZIP 3 <br /> LICENSE C-57 C-61 D-09 11 Other NUMBER ! l EXPIRATION DATE ".13 "`f <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y_ Township Range Section <br /> INTENDED USE 3LDomestic/Private C Irrigation/Agricultural 0 Industrial Water Quality Monitoring O Soil Sampling/Characterization <br /> ii Public Water System <br /> If different from Owner: ater System Name �oMactl�ame or Phone Number <br /> TYPE OF WORK n New Well X Replacement Well ❑ Well Alteration/Modification tl Other <br /> Monitoring Well(s) #of wells C Soil Boring(s) _ #of borings i- Geotechnical #of borings <br /> ❑ Out-Of-Service Well o Out-0f-Service Well Renewal a Cross-Connection Repair <br /> New Pump Pump Replacement ❑ Pump Repair 11 Raise Well Casing <br /> WELL CONSTRUC ION <br /> Drilling Method)CMud Rotary L; Air Rotary Auger U Cable Tool L! Push Point 11 Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom Gravel Pack/Gravel Size f� _in diameter <br /> Ll Conductor Casing in diameter / Conductor Casing Depth _ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched e,?/ _ 'i Steel 'Plastic r Stainless Steel D Other <br /> Grout Seal Depth " ft r, Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> I Bentonite(20%solids) [1 Other <br /> Grout Placement Method A Pumped -i Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By N Driller Pump Contractor LI Other <br /> Concrete Pedestal 1.Dimensions:Width_4L-_,ti`It Length ft Thick in CChristy Box n Stove Pipe <br /> PUMP Submersible r' Turbine I' Other HP Pump Set • ft Standing Water Level %L/ 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS CO MPE SATION LAWS. <br /> MINI M HOU VAN NOTICE REQUIRED FOI1,INSPECTIONS- P ASE CALL(209) 953-7697 <br /> SIGNED 1. _ TITLE <br /> _7 �' �? .�'< �I'IIG BATE <br /> lo- <br /> *�/ <br /> '7 <br /> t V <br /> ( IN <br /> ,a <br /> A:D,LPARTMENT USE ONLY may' <br /> App!'icationAccepted By_ Dateto <br /> L <br /> � Area � i Employee ID# <br /> Grout Inspection By Date ! - ❑ SPECIAL Well Permit <br /> Pump Inspection By _ Date C LAll ❑ WAIVER Received <br /> Soil Boring Inspection By Date _ Constructed Well Depth ft <br /> COMMENTS CrS(J//(� Vll .l. -r_d� �P�L�3�T _ <br /> PE SC Received Check#/ Amount PermiU <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> ;""A- <br /> �pt <br /> o ; �A-_c <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/0/12 <br />