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�ih�l Scan 51i.��n <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)46&3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIOIJS EXPIRES 1 YEAR FROM DATE ISSUED <br /> of <br /> JOB ADDRESS I 4 ��n^ art-TO CITY/Zip / <br /> DROSS STREET r" ^'SA�t iJ APN 8 S O-//� �I ® PARCEL SIZE 9 � LAND USE`1�AP(JPLIC�A7TION# a <br /> OWNER NAME Xs�b-L �1 C �/ R,0S PHONE L l r 7 -7 2—) <br /> OWNER ADDRESS �A)�'w/��,/�q�� //�J CITY/STATE/ZIP <br /> CONTRACTOR /V {/.-A t✓,}4v/�a�/> 1)A1, PHONE <br /> CONTRACTOR ADDRESS / O '/ ` CITY/STATE/ZIP �!! '�0�//!U IZ'�(l�Yq-� � '�✓r/ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP / <br /> LICENSE , LC-57 C-61 ❑ D-09 ❑ Other NUMBER� EXPIRATION DATE f? <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE ❑ Domestic/Private rigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampllng/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System NameContact Name or Phone Number <br /> TYPE OF WORK Whew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Wells) #of wells ❑ Soil Boring(s) 4 of borings ❑ Geotechnical 0 of borings <br /> ❑ Out-01-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pum ❑ Pum Replacement El Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method>Iud Rotary 11Air Rotary ❑.Auger D Cable Tool 11Push Point ❑ Other <br /> Proposed Well DepthL otit Excavation 1.6 in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well2sz? 11 <br /> Casing <br /> Sieal Depth Diameter/ In Thickness/Gauge/ASTM E) Neat Cement(94 lb bag/5� f0 gel water SteelyPlastic <br /> and Cement tainleJ�,slSteel ❑ Other <br /> C>8 ` V sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Methotl'4fPumped Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By >Triller n pump Contractor 11Other <br /> 11 Concrete Pedestal� Dimensions:Width ft Length It Thick in -❑ Christy Box ❑ Stove Pipe <br /> PUMP submersible- Turbine ❑ Other HP Pump Set ft Standing Water Level tt <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 /> MI M 24 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209))953-77697 <br /> SIGNED oM- TITLE A - DATE , 6 <br /> 171 TIT La7l <br /> A H A 14TrE <br /> J� E /P/rARTMENT U E NL <br /> Application Accepted Date f 3 Zd 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 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> o� 3. A 5-1 -K 5twol 4 864 <br /> EHD 4306 WELL/PUMP PERMIT <br /> 4/30/12 <br />