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PE -- <br />EE WELUPUMP PERMIT <br />SAN JOAQU OUNTY NVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT GALL 2U9 9J3-/b'd/ FOR INSPEGTIUNS <br />r-ArIMr-0 I IIr-AM rnUrvr LOA Ir- raavF-u <br />Received <br />B <br />Check#/ <br />ash <br />Amount <br />Remitted <br />r <br />JOB ADDRESS <br />C7, J I L� L Ay t: CITY/ZIP <br />A <br />CROSS STREET��iS) <br />/I 2 <br />APN 1 CS, J �%UO CJ PARCEL SIZE <br />LAND USE APPLICATION # <br />OWNER NAME <br />7`,� Imo! �V } 1Lre,� ___ <br />PHONE <br />kAj JL -tLA <br />OWNER ADDRESS <br />[ <br />I'( 76 �Oez �-,n c..yVl l�Y CITY/STATE/ZIP <br />6 -'Lt- tL- <br />�- ` S Y( - <br />CONTRACTOR 11�7�/(J� ��Jt 7Li LCJ�L�S r �4 _ PHONE -:31 ZC' <br />CONTRACTOR ADDRESS J L� /�2c�+J� �r� CITY/STATE/ZIP�C T { I C?J / <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE tiC-57 'I C-61 Ii D-09 [I Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER == �-f -~ % - - EXPIRATION DATE z�5/ <br />GEOGRAPHICAL INFORMATION: Coordinates X Y _._ _ Township _ Range Section <br />INTENDED USE ! i Domestic/Private i Irrigation/Agricultural [_I Industrial Water Quality Monitoring L Soil Sam piing/Characterization <br />[ I Public Water System <br />If different from Owner: ater System Name Contact Name or Phone Number <br />TYPE OF WORK n New Well 1 11 Replacement Well ❑ Well Alteration/Modification f] Other <br />Monitoring Well(s) # of wells ❑ Soil Boring(s) If of borings Geotechnical # of borings <br />U Out -Of -Service Well U Out -Of -Service Well Renewal /Cross -Connection Repair aTirk-t- <br />ivew rump rump neplacemem u rump repair a False vveii uasmgy . <br />WELL CONSTRUCTION <br />Drilling Method u Mud Rotary l7 Air Rotary Auger L Cable Tool LI Push Point ❑ Other <br />Proposed Well Depth_ ft Excavation in diameter ❑ Open Bottom I , Gravel Pack/Gravel Size in diameter <br />Ll Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 'J Steel L Plastic ❑ Stainless Steel _ Other <br />Grout Seal Depth ft ,: Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />LI Bentonite (20% solids) I I Other <br />Grout Placement Method I l Pumped =1 Free Fall - Other Retardant / Accelerator (name) <br />PEDESTAL Installed By 1 Driller 7 Pump Contractor LI Other 1 <br />Concrete Pedestal I Dimensions: Width It Length ft Thick in -i Christy Box r Stove Pipe <br />PUMP Submersible! Turbine I 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 COMPEN ION LAWS. <br />MINI UMTOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED"�%TITLE /' - ' - DATE - - ' <br />DE ARTMENT USE,ONLY <br />Application Accepted By Date t",' _ Area Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS �1<�� 12A1 <br />T <br />m <br />D <br />v <br />O <br />m <br />m <br />N <br />w <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check#/ <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />ell ID#LM <br />11141 <br />kAj JL -tLA <br />E30/12 6 �J� /I6 -7? <br />40 HD 4 !/ (/ WELL /PUMP PERMIT <br />