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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL(209)'� <br />953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />J �L <br />war <br />CITY/ZIP <br />��� <br />fa430 <br />�i <br />CROSS STREET <br />� IV <br />4 P N�f; <br />PARCEL SIZE ✓ <br />LAND USE APPLICATION # <br />OWNER NAME <br />f <br />a I t�, / "` <br />J <br />� � l� I � i <br />PHONE ✓ ' o 9 <br />OWNER ADDRESS <br />� <br />� VV <br />j <br />IP o r tip <br />%�1 <br />—! ' ��ITy/STATE2IP <br />' I C 7 J ✓ ./ � `1 <br />CONTRACTOR <br />f) �1 /' I r / `r i %� <br />1 C '► 1 LL �fJ M' <br />PHONE <br />CONTRACTOR ADDRESS <br />V U <br />�p )5� ► LJ <br />9 CITY/STATE/ZIP <br />SUBCONTRACTOR <br />PHONE —9 �7 <br />SUBCONTRACTOR ADDRESS ._ CITY/STATE/ZIP <br />LICENSE C-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township n t{on __ <br />INTENDED USE _j Domestic/Private Irrigation/Agricultural ❑ Industrial Water Quality Monitoring SOI ling/ a i <br />I Public Water System <br />If different from Owner: Water System Name Contact Namurm <br />TYPE OF WORK Y New Well Replacement Well ❑ Well Alteration/Modification i Other <br />C� # of borings # of borings <br />F] Monitoring Well(s) # of wells ❑ Soil Boring(s) Geotechnical <br />I Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />I New Pump I.j Pump Replacement 9 Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method , Mudota 1 Air Rotary Auger [I Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation ttf in diameter Open Bottom X Gravel Pack/Gravel Size 1 L/' in diameter <br />Conductor Casing _ _ in diameter / Conductor Casing Depth ft <br />Well Casing Diameterj` in Thickness/Gauge/ASTM Sched `^ Steel Plastic Stainless Steel Other <br />Grout Seal Depth�L. j ft Neat Cement (94 lb bag/5-10 gal water) Sand CementI L sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method ` Pumped Free Fall Other Retardant / Accelerator (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 ❑ Submersible 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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM.,�4 HOUR.AdVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (2091953-76a7 <br />DEPARTMENT U.SE ONLY <br />Application Accepted By 4.7 ! ___ Date 1 ( � Area v 5-11") Employee ID#P1-' <br />l 5- <br />Grout Inspection By ____. __ Date ❑ SPECIAL W@II Permit <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS Av-,6Z.�-� <br />k ,r,x, S ,l i VLM <br />1tiAti t N a <br />Date <br />Date _ <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />"i `,, 4v r ,rvtAv rN G Wi.,- <br />T <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#/ <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # Well ID# <br />fa430 <br />�i <br />s, �� <br />5R oy111,11 <br />, <br />XpMurk <br />EHD 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />