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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.s1Gov.or2/ehd EXPIRES 'I YEAR FROM DATE ISSUED <br />JOB ADDRESS 121.0 2'.A CITVITIP `ra ;'Z \n <br />CROSS STREET r—N Q,,!,3 1�r`t- , l _ APN 2 a 3 - `S kD0 —O-1 PARCEL SIZE , LAND USE APPLICATION # <br />OWNER NAME CQ,S AM YI C�Q���c C\ i" PHONE <br />OWNER ADDRESS } CITYISTATEIZIP Un) nYrV-C W . CA ctjb%�O <br />CONTRACTOR u,x1---17+C r 1%YN _ PHONE <br />CONTRACTOR ADDRESS t)FX�X �I"F�fr� CITYISTATE/ZIP -C+rnC.LA /C.& /QS --S-1 <br />SUBCONTRACTOR/CONSULTANT M,d�Gt \G Cra\'r1GPY1'� �r ` PHONE R% %Q " 9'L`F' -1000 <br />SUBCONTRACTOR/CONSULTANT ADDRESS S340 Ernba rn,A(Ptf(1 fzor\ve. CITYISTATEIZIP Wco <br />LICENSE L//C-57 O C-61 0 D-09 0 Other NUMBER 150 EXPIRATION DATE <br />BILLING PARTY: 0 OWNER iJ CONTRACTOR AUBCONTRACTORICONSULTANT <br />DoMEsnc WELL SAMPLING: CI GeneraNineral/Coliform Bacteria (4391) n Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial D Water Quality Monitoring 0 Soil Sampling/Characterization <br />D Public Water System <br />If o!fferent from Owner. Weiler System Name ConlaU Name or Phone Number <br />_ `- -j—' <br />DEt ATMENT U E /QNLY/'j� <br />Application Accepted By <br />Groutlnspedi n Date <br />FWq <br />Pump Inspe Dale <br />Soil Boring Inspec Ion y a& Date <br />COMMENTS T> <br />Data c _ PermlU <br />/..S u-- <br />EHD 47 -Da 61I1I20+9 <br />q(�- w- 0gOq <br />btit <br />Area Employee ID# Pa Ora <br />a <br />(_l SPECIAL Well Permit: <br />1-1 WAIVER Received <br />Constructed Well Depth _ <br />Invoice # I Well ID# <br />WELL /PUMP PERMIT <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />D Monitoring Well(s) # of wells U/Soli Borings) 1 0 of bodngs Geotechnical # of borings <br />D Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION 1 <br />/ <br />Drilling Method 0 Mud Rotary 0 Air Rotary Ff Auger 0 Cable Tool D Push Point 0 Other <br />Proposed Well Depth '110-45 it Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size In diameter) <br />D Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter __i&_ in ThicknesslGauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth LW -45 it 0 Neat Cement (94 Ib bag15-10 gal want) 0 Sand Cement sack mW7 gal water <br />n Bentonite (20% solids) D Other <br />_Grout Placement Method U Pumped 0 Free Fall U Other _ 0 Retardant I Accelerator name <br />W0 <br />PeoeSTAL Installed By D Driller 0 Pump Contractor D Other <br />Concrete Pedestal ODimensions: Width it Length It Thick in 0 Christy Box 0 Stove Pipe <br />PUMP 0 SubmersibleO Turbine 0 Other HP Pump Set_ ft Standing Water Level it <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 />MIN 48 H!Q•11(,t ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED '"'�\I�/ CAR /l <br />TITLE 4DWYyCY DATE 112 At <br />_ `- -j—' <br />DEt ATMENT U E /QNLY/'j� <br />Application Accepted By <br />Groutlnspedi n Date <br />FWq <br />Pump Inspe Dale <br />Soil Boring Inspec Ion y a& Date <br />COMMENTS T> <br />Data c _ PermlU <br />/..S u-- <br />EHD 47 -Da 61I1I20+9 <br />q(�- w- 0gOq <br />btit <br />Area Employee ID# Pa Ora <br />a <br />(_l SPECIAL Well Permit: <br />1-1 WAIVER Received <br />Constructed Well Depth _ <br />Invoice # I Well ID# <br />WELL /PUMP PERMIT <br />