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'r <br /> ` 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 /> v: <br /> Sly f},y� Ac`r 96� 7 m <br /> - a <br /> JOB ADDRESS A1C CITY/ZIP_ <br /> �CoAPN Z _5 O Jv 1 Ci �- o <br /> CROSS STREET fl• PARCEL SIZE AND USE APPLICATION# p <br /> I -7 Y9 <br /> OWNER NAME ', >k 16 �A _ ._ P��//H,,..ONE <br /> OWNER ADDRESS 017 ' �s CITY/STATE/ZIP76i_��A <br /> CONTRACTORt .� �( _ PHONE �9l2'�}� <br /> CONTRACTOR ADDRESS 3 oU� ,i d CITY/STATE/ZIP �/�C �/7 / ✓`�v <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE iiC>Z7 `) C-61 :I D-09 Other NUMBEF� EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Omestic/Private F. Irrigation/Agricultural U Industrial ',_l Water Quality Monitoring L Soil Sampling/Characterization <br /> I Public Water System �-�:— <br /> If different from Owner: Water System Name tactNName or Phone Number !1C <br /> TYPE OF WORK Blew Well I I Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> If of borings #of borings <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) C Geotechnical <br /> ❑ Out-Of-Service Well U ❑Out-Of-Service Well Renewal Cross-Connection Repair 2019 <br /> 9 <br /> °Cl New Pum T' Pump Replacement ❑ Pump Repair n Raise Well Casing "4lV JO <br /> WELL CONSTRUCTION :l <br /> HEAL 1�O pME�rUN7�, <br /> Drilling Method �d Rotary Il 7 Air Rotary Auger Ll Cable Tool L) Push Point l l Other A A� <br /> Proposed Well Depth ,To m ft Excavation !2/y in diameter ❑ Open Bottom gavel Pack/Gravel Size in diameter <br /> Ll Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched JOK 2( Steel Wlastic U Stainless Steel -1 Other <br /> Grout Seal Depth DO ft - Neat Cement(94 Ib bag/5-10 gal water) G Sand Cement -sack mix/7 gal water <br /> entonite(20%solids) `I Other <br /> Grout Placement Method !l Pumped -1 Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By El Driller mp Contractor I Other <br /> Concrete Pedestal "Dimensions:Width ft Length ft Thick -, Christy Box r Stove Pipe <br /> PUMP ubmersibler 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 CTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CO ENSATION LAWS. <br /> MINI UV24 DVANC OTICE REQUIRED FOR INSPECTION PLEASE CALL (209) 953-7697 <br /> SIGNED__ ___ TITLE_ YR /7rs DATE <br /> l <br /> PT, <br /> EPARTMENT U 'E NLY _ j -_f <br /> Application Accepted By Date� .� _ Area CCI Employee ID# 1 -t4 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date +� <br /> fj WAIVER Received <br /> G <br /> Soil Boring Inspection By _ Date Constructed Well Depfh / ft <br /> COMMENTS < �— 1' <br /> 1. L t k 1( <br /> Is 4 1- I r� —W, i* Ort L I c w tI <br /> l� <br /> PE Sc Received Che <br /> Date Amount Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> y 3Lt 201319 �� D ��l�r, <br /> �603 <br /> EHU 43-06 <br /> 4/30/12 WELL/PUMP PERMIT <br />