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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 /> JOB ADDRESS t _� O 1 1,��1 1 CITY/ZIP L-M( C f ��r31 U;� D <br /> CROSS STREET '(. ✓r APN PARCEL SIZE LAND USE APPLICATION# a <br /> m <br /> CIO <br /> OWNER NAME ( P`H'O/NE / n <br /> OWNER ADDRESS 2 j �D �y� _____ CITY/STATE/ZIP Lo I' ! _ a 9 u <br /> CONTRACTOR V J W ,J1Cj��l �,�,(✓�/G'� I�/I� n PHONE 3,2y - 7 7q Z <br /> CONTRACTOR ADDRESS 3��\ )(A� l tf2 1` CITY/STATE/ZIP 1"C�_ mil/ , ✓� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS 4j 6 , CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER ^ EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y_ Township .._ Range Section <br /> INTENDED USE Domestic/Private --Arrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name fact Name or Phone Number <br /> TYPE OF WORK 7CNew Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) _ #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method /Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> r <br /> Proposed Well Depth_I Id2 It Excavation 17 Y,1 it in diameter Open Bottom YGravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 1.2ir in Thickness/Gauge/ASTM Sched Jl _ -KSteel Plastic Stainless Steel Other <br /> _,::Grout Seal Depth r ft Neat Cement(94 lb bag 5-10 gal water) --#-fiend Cement —�-�r— sack mix17 gal water <br /> T Benton:e(20%solids) "Other <br /> Grout Placement Method ?(Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By XDriller Pump Contractor_ Other <br /> n Concrete Pedestal (Dimensions:Width ft Length_ 5 ft Thick__L2_in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It Standing Water Level ft <br /> 1 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 L S. <br /> M I UM 2/4 �i10 R VANCE NOTICE REQUIRED FO NSP CTIONS - PLEASE CALL (20�953- 697 /j` <br /> SIGNED ( ` _ __ TITLE __ __ _ _ DATE v/ <br /> h � <br /> A. <br /> R <br /> r ll , <br /> E O <br /> DEPARTMENT USErNLY <br /> Application Accepted B Date Z (� Area Dy _ Employee ID# <br /> Grout Inspectio Date Z _ ❑ SPECIAL Well Permit <br /> Pump Inspection By Date_ ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS -?0- e-Ze - FG�% / 4 /V/ <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Rxi, Cas Remitted Service Re uest# <br /> H�6 1 �J �- a13�-3 3�k1 `'� ► 19 I`� 5� �-l .z�`-� <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />