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WELUPUMP PERMIT � Do SAN vOAOUiN COUNTY ENVIRONMENTAL HEALTHLTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA��5 - �2C {f�9)46 - <br /> NOWREFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTiO S EXPIRES 1 YEAR FROM DATE ISSUED <br /> c r ' fJ./!'Y�. w. <br /> ,IOB ADDRESS (` r m <br /> D CITY/ZIP�li r � �r � N <br /> ROSS STREET -S APN PARCEL SIZE LAND USE APPLICATION# � <br /> OWNER NAME ''��(L �C� '` ZZ�I ',y" �' PHONE -e ` �y �/ <br /> OWNER ADDRESS �/" ✓� CITY/STATE/ZIP <br /> 1 _' ­7'7 <br /> CONTRACTOR :;4 PL<1 S, y <br /> - _�� PHONE / _ <br /> `� J7 <br /> CONTRACTOR ADDRESS J '/ ­y CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE „ -57 C-61 D-09 Other NUMBER i J 6_(' EXPIRATION DATE C� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE L Domestic/Private p�rigation/Agricultural L Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> L Public Water System <br /> If different from Owner: Water ystem Name Contact ame or Phone um er <br /> TYPE OF WORK ^New Well Replacement Well I Well Alteration/Modification I Other <br /> ❑ Monitoring Well(s) #of wells 1 Soil Boring(s) #of borings Geotechnical #of borings <br /> o Out-Of-Service Well _1 Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump I I Pump Replacement L Pump Repair o Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,-i6lud Rotary 1 Air Rotary Auger ❑ Cable Tool Push Point L Other <br /> Proposed Well Depth_2'L.-� ft Excavation /-6 in diameter Open Bottom ravel Pack/Gravel Size in diameter <br /> Conductor Casing_ in diameter / Conductor Casing Depth ft <br /> Well Casing DiameterA in Thickness/Gauge/ASTM Sched -0 Li Steel,' Plastic Stainleep Steel Other _ <br /> Grout Seai Depth �-s 0 ft Neat Cement(94 lb bag/5-10 gal water) )land Cement sack miyd7 gal water <br /> i Bentonite(20%solids) Other <br /> Grout Placement Method*ePumped I Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By >Zriller 1 Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> of <br /> PUMP >4ubmersible Turbine Other HP L 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 CAL'FORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINMUM 24 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209)953-716971 <br /> SIGNED v3+— TITLE Cti�N� _ DATE <br /> Y \ <br /> B <br /> J <br /> M <br /> } <br /> F; J. , <br /> E ARTMENT U E NLY <br /> Application Accepted B ` Date J Zd' `� Area v( Employee ID# a <br /> Grout Inspection By Date I ❑ SPECIAL Well Permit <br /> Pump Inspection By v Date Cl WAIVER Received <br /> Soil Boring Inspection By Date onstructed We I Depth <br /> N <br /> COMMETS ���1 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 1 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />