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TN 414 5utl/11 0S <br /> 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 /> l� f o <br /> rX <br /> JOB ADDRESS ) � �r l LI VL�GI �� � CITY/ZIP �fJd'�-- _ "1 l 9.536 F' m <br /> CROSS STREET R t I/N" •d f APN 4!�-a3 e7' 79 PARCEL SIZE ULLAND USE APPLICATION If ? <br /> OWNER NAME CA <br /> A- A14-✓L L C.O fiHnNt'r l t� �I Wl/7 DPHONE Z 331 - -7 , 7 2- <br /> OWNER ADDRESS"�IhC,I�D Z /` �L V/w CITY/STATE/ZIP <br /> Y ,/�_� _��//�-�p�%�✓ <br /> CONTRACTOR f a ps-�1l16(,"V T" I1// "41 {PHONE �jz�l�7�Ca <br /> CONTRACTOR ADDRESS I b'tr"'-S I'�t% / CITY/STATE/ZIPf I r 'esr " e< /. Y5-7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE C-57 Il C-61 ❑ D-09 ❑ Othef NUMBER 'l EXPIRATIONDATE_24e?L 7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE DOmeslic/Pdvate ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> [l Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK XNew Well n Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Wells) #of wells ❑ Soil Boring(s) If of borings ❑ Geotechnical #of borings <br /> n Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> FI New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodXMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth x249 it Excavation /Z in diameter ❑ Open Bottom ](Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter* in Thickness/Gauge/ASTM Schad 2) u Steel 1<hlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth-11W it n Neat Cement(94 lb bag/_ 5 f tLater) ❑ Sand Cement sack mW7 gal water <br /> XSentonite(20%solids) ❑ Other <br /> Grout Placement Method Xpumped D Free Fall ❑ Other n Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br /> n Concrete Pedestal❑Dimenalons:Width ft Length it Thick in ❑ Christy Box n Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set it Standing Water Level it <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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76997 <br /> SIGNE 1 L TITLE 4J✓`t 1`eN DATES-e-17- <br /> 0 <br /> Z <br /> E liy <br /> r <br /> WX <br /> M <br /> LP <br /> ARTMENT USE ONLY <br /> Application Accepted Date 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 _R <br /> COMMENTS <br /> PE Sc Received a Amount Date Permiu Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> ff 32�9� SIB n Sl-oo7te7y <br /> 9 o_7 -;f <br /> EHD 4306 WELL/PUMP PERMIT <br />