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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 <br />CALL <br />209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS ` (�% U <br />W �/ <br />�G <br />CITY/ZIP �' �K—"l r 0,1 <br />l� <br />CROSS STREETf ,IGS/ <br />APN <br />I L) 1 � (� PARCEL SIZE IV- Y1 LAND USE APPLICATION If <br />OWNER NAME To4�.) 6 ti <br />rf �+ <br />L'" <br />/ �/ <br />PHON�EJ 2- e) ` - �e� ` - L/ L/ <br />OWNER ADDRESS '�©L <br />I `<< —1 <br />/c <br />CITY/STATE21P <br />/!V <br />CONTRACTOR l_E'�t 7L/�Y. l <br />lJ� 11 V <br />'✓ � <br />J <br />�/ T . E V) PHONE �(� <br />CONTRACTOR ADDRESS ` V <br />�(� Ll <br />P-4-1 <br />'/ <br />CITY/STATE/ZIP C r`D�eJ �ys-('*' <br />I <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />_ <br />CITY/STATE/ZIP <br />LICENSE C-57 C-61 <br />D-09 Other <br />I <br />/ <br />NUMBER L q -� EXPIRATION DATE l <br />GEOGRAPHICAL INFORMATION: Coordinates X _ Y Township Range Section__ <br />INTENDED USE I Domestic/Private Irrigation/Agricultural u Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br />1 Public Water System. _ <br />If different from Owner: Water System Nam Contact Name or Phone Number <br />TYPE OF WORK a New Well Replacement Well ❑ Well Altera n/ i ❑ Other <br />❑ Monitoring Well(s) # of wells ❑Soil Bor' Geotechnical # of borings <br />"XOut-Of-Service Well ❑ Out -Of- I- ross-Connection Repair <br />New Pump Pump Replacement Pump Repair�$aise Well Casing <br />Drilling Method Mud Rotary ❑ Air Rotary Auger Cable Tool r I Push Point FI Other <br />Proposed Well Depth_- ft Excavation 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 _i Steel ❑ 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 />Bentonite (20% solids) Other <br />Grout Piacement Method Pumped Free Fall Other Retardant / Acceler3tor (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP 'i Submersible Turbine Other HP Pump Set It 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 />MINI � 24 HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9-5-13-7697 <br />SIGNED TITLE C w � 1 Z DATE r� l <br />D E P A A I` Z. -11 U S E v v L <br />Application Accepted By u ate( Area y/l Employee ID# wed-sed <br />Grout Inspection By Date � SPECIAL Well Permit <br />Pump Inspection By Date I 1 WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />PermiU <br />Service Request # <br />I ice # Well ID# <br />'136- <br />17 <br />�,N <br />�� <br />� u 5 <br />� I <br />�'> c i � L <br />FX <br />EHD 4306 WELL /PUMP PERMIT <br />4/30/12 <br />