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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 /f / CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /�✓�l� vV+ dN� Ay /� CITY/ZIP `7b <br /> a <br /> o <br /> CROSS STREET APN OSS-D70—d/r ppRCEL SIZEOOLAND USE APPLICATION#j m <br /> OWNER NAME O4*g A'Ie!ft B"n PHONE <br /> OWNER ADDRESS o737S k/ Rn, CITY/STATE/ZIP L4 9S2Y2 <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS . CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE C-57 ❑ C-61 F D-09 ❑ Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE ❑ Domestic/Private Xlrrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 11 Public Water System <br /> If different from Owner: Water System Name -------C—on—ta—cf-Rame or Phone Number <br /> TYPE OF WORK I New Well ❑ Replacement Well ❑ Well Alteration/Modificallon ❑ Other <br /> Monitoring Wells) #of wells Il Soil Boring(s) #of borings I Geotechnical If of borings <br /> Out-Of-Service Well I Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump ❑ Pump Replacement r Pump Repair I i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable 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 it <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft _ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall I I Other I 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor a Other <br /> J Concrete Pedestal I 'Dimensions:Width it Length it Thick in ❑ Christy Box Stove Pipe <br /> PuMP ❑ Submersibl urbine ❑ Other HP_jfiW±0 Pump Set It 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> IMUM 24 HO DVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> DEC- <br /> Ep <br /> oQ <br /> 015 <br /> UN1 <br /> L <br /> _ DEPARTMENT USE ONLY RTMEM <br /> Application Accepted By Date /�4 f s Area Employee ID# Gb71"'c) <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection @y 1 Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received CCheek Amount Permit/ <br /> Codes Info B as Remitted Date Service Re uest# Invoice If Well ID# <br /> 4M oso g01 4,�3-o-P i o1 IS SP?pa_j <br /> EHO 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />