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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 CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />'•: 1 -. i a.e f r�/ 'I _yam ( <br />JOB ADDRESS jj - 1 O� \ !2 . I, A/# ('iii` 6t` 1 LtJt _ _ -__ CITY/ZIP ��_r�}f�Q <br />CROSS STREETY_ APN D l _PARCEL SIZE ° i.` LAND USE APPLICATION # _ <br />OWNER NAME 77kQ[��I�� —_ PHONE <br />OWNER ADDRESS <br />CONTRACTOR j r ` <br />CONTRACTOR ADDRESS 0. R13 -'e <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE VC -57 C-61 D-09 <br />CITY/STATE/ZIP ��p r4 l/��, (75L 1. <br />(_ <br />PHONE / 3� `�7(7 — �1--I 9. <br />_ CITY/STATE/ZIP ?'vv s </ <br />PHONE <br />CITY/STATE/ZIP <br />711741 <br />EXPIRATION DATE_ <br />GEOGRAPHICAL INFORMATION: Coordinates X _ 111 11 —=— Township Range _ Section_____ <br />INTENDED USE 1 Domestic/Private ' ><"gation/Agriculture 0 h 1��1*ter Quality Monitoring Soil Sampling/Characterization <br />❑ Public Water System\\_ <br />If different from Owner: Water ystem Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well Replacement Well Vell Alteration/Modification �, Other Ic 4,+T=s LI - no Vut-e r L•' t"-4cl <br />❑ Monitoring Well(s) # of wells i Soil Boring(s) _ If of borings Geotechnical # of borings <br />F1 Out -Of -Service Well 1}COut-Of-Service Well Renewal ❑ Cross -Connection Repair <br />New Pump Pump Replacement itPum Repair Li Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger table Tool Push Point 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 a Plastic i Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) rJ Sand Cement sack mix17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By i Driller Pump Contractor Other <br />U Concrete Pedestal Dimensions: Width It Length ft Thick in Christy Box Stove Pioe <br />PUMP ❑ Submersible Turbinil HP Pump Set It Standing Water Level It <br />I HEREBY CERTIFY THAT I HAVE PREPARE T'HIS'14ACATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAOUIN COUNTY ORDINANCES, $1`ATl� LA S AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CAUIN' RS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MMU2H URA CE NOTICE REQUIRED FORINSPECTIONS- PLEASE CALL (209)y953-7697 <br />SIGNt-. / TITLE C/l) f ✓ i'i I {l C f _ DATE r('//l� �� '2C <br />f� DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS Lz- 'QA, <br />Date —5 <br />Date <br />Date <br />Date <br />Area Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />rn <br />A <br />D <br />v <br />v <br />m <br />m <br />En <br />En <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />CChechW <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />ell ID# <br />0- <br />JL 1L�jJLX1VJLJL <br />hArl <br />EHD 43-06 WELL/PUMP PERMIT <br />4/30/12 <br />