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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1866 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> t 1 N ��L t:tTY>�IP ,.� <br /> Joe ADDRESS ` O <br /> CROSS STREET PARCEL SQE LAND USE APPLICATION# <br /> .OWNER NAME -----w I�/V� C� PHONE <br /> OWNER ADDRESS / )/C�-(,C�+rv�/`� CITY/STATE0P n(� '1/� �j y/� <br /> ICONrRACTOR L. v�j rJ -}--• J / PHONE <br /> n 2-0 (' -!/Z�t:�- /-/7r <br /> CONTRACTOR ADDRESS -, (UO / t r T! `h CrTY/u7ATE21P 01(.ie �rc) , C-4 "7l 3l <br /> :SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrTY/STATEEMP <br /> LICENSE C-57 C-61 D-09_ i i Other NUMBER l7 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domeslic/Privale - InigationlAgricultural _=Industrial %:Water Quality Monitoring Soil Sampling/Characterization <br /> public Water System <br /> It diRerent Gam OwrxrWater sys or vrone <br /> Niant— <br /> TYPE OF WORK New Well Replacement Well D Well ARerationlModification Other <br /> Monitoring Weil(s) #Of Wells D Soil Borings) a of twangs _ Geotechnical >R or txuv+gs <br /> )Out-Of-Service Well D Out-OfService Well Renewal Cross-Connection Repair <br /> _ New Pump Pump Replacement D Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> j Drilling Method Mud Rotary Air Rotary -Auger Cable Toot 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 Sched -Steel Plastic - Stainless Steel Other <br /> Grout Seal Depth It ::Neat Cement(94/b bag6-1 0 gal water) _:Sand Cement sack mix/7 gal water <br /> Bentonrte(20%solids) Other <br /> Grout Placement Method - Pumped :]Free Fall ''Other Retardant/Accelerator(name) <br /> PEDESTAL installed By -i Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick 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 j <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS- 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS i <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPE SATION WS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED <br /> �FOR INSPECTIONS <br /> SIGNED TITLE �{J{� �'s+L /�` DATE <br /> S <br /> if <br /> Fill <br /> -� <br /> j ( <br /> it <br /> I <br /> n <br /> i <br /> ,3�� <br /> DEPARTMENT USE <br /> oO LY r� <br /> Application Accepted Date 1 -[ 4f Z. Area_-� Employee IDa <br /> Grout Inspection ` Date SPECIAL Well Permit <br /> Pump Inspection By (,'}tit�trt h� Date 10 lil, Z— WAIVER Received <br /> Soil Boring Inspection By Date -_ Constructed Well Depth it <br /> COMMENTS ,la,� r c o a a�{/�C - �'}Oi.+^s.u�c�ot�, PRo s.A y <br /> PE SC Received Cho" i Amount PermW - "-.__ - <br /> Codes Info B Cash Remitted Date cSevce R uest# Invoice i Well ID# <br /> L{-xo /791 1SVZD <br /> - --.- <br /> EHO 43-06 <br /> S'0 <br /> 01 <br /> J8 <br />