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r � ^ <br /> r <br /> ` WELUPUMP PEONT Q LE14 , 7'� <br /> ySZ� 468-3420 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186f3 EAST HAZELTON AVENUE-STOCKTON C <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> 1 <br /> JOB ADDRESS I �' CITY/ZIP ,\ L n <br /> CROSS STREET r APN 05 PARCEL SIZL_ lk%,- AND USE A LIGATION# x <br /> m <br /> OWNER NAME 0,V6 i, PHON <br /> l ` `OWNER ADDRESS CITY/STATE/ZIP L <br /> '�J l� <br /> CONTRACTOR Y / PHONE - <br /> CONTRACTOR ADDRESS Cl TAT <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS ClTY/ TAT IP <br /> LICENSE C 57 I_ C-61 I D-09 I Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private I- Irrigation/Agricultural I- Industrial a r Qua I Monitoring Soil Sampling/Characterization <br /> I I Public Water System <br /> If different from Owner: Water 62MM Name y Contact Name or Phone Number <br /> TYPE OF WORK I New Well (I Replacement Well 11 Well Alteration/ o 'fication I I Other <br /> I Monitoring Wells) #ofyvells Soil Boring(s of borings I I Geotechnical_��"6 in s <br /> I Out-Of-Service Well Out Of-Se Ice Well R ne I I I Cross-Connection Repair RECEIVED <br /> I New Pump ❑ PumpReplacement I Pum air, I I Raise Well CasingCE►VED <br /> WELL CONSTRUCTIO PR 0 7 2015 <br /> Drilling Method Mud Rota El Air Rotary I Auger I I C le of - Push Point - Other <br /> Proposed Well Depth�ft Excavation 1� dia eter I Open Bottom ❑ Gravel Pack/Gravel S - CQt%filter <br /> Conductor Casing in diameter / C nductor C ing Depth ft HEALTfi' EepgR MEN-, <br /> Well Casing Diameter� in Thick es auge/ASTM c ed Steel _I lastic -I Stainless Steel I i Other <br /> Grout Seal Depth 1 ' ft Neat ent b bag/5-10 gal wafer) Sand Cement sack mix/7 gal water <br /> I Bentonite(20%solids) I_ ther <br /> Grout Placement Method I Pumped I Free F I er rdant/Accelerator(name) <br /> PEDESTAL Installed By I I Driller I Pum C tr ctor I Other <br /> I Concrete Pedestal 1 Dimension idt t Length Z ft Thick in 1- Christy Box I Stove Pipe <br /> PUMP Submersible I Turbine-,,I Oth HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I_HAVE PREP THIS PPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORD,IKfAI ST E L AN RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVII WITH T EC LIF IA N ACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSA ION LAW <br /> MI MU 2 UR D A E OTICE REQUIRED F INSPE 4,TTION - PLEASE CALL(209)9 3-7 97 <br /> SIGNED ^ TITLE Yli DATE L �— <br /> 4, 1 <br /> 12 <br /> I <br /> t <br /> - t <br /> � sa <br /> A <br /> !M „x <br /> �.: t ft55G7tX)Y ' <br /> ' J t i..:e .nn i..... .••'i:'._;.. ...� '.. .. .-. �.hn as ..rS+i_ <br /> Mw hOflMkll <br /> DEPARTMENT USE ONLY 7 <br /> t I © �[e Employee Accepted B Date Area Emy p oyee ID# <br /> Grout Inspection By Date ❑ iSPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring InsDection By Date IAJConstructed Well Depth ft <br /> COMMENTS tN�° ��'""�� Teti <br /> PE SC Received (-Check Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By S Remitte Service Re uest# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 L7 <br />