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I� ✓• <br /> r 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 /> G 10 ? ( G to <br /> JOB ADDRESS 9 1� P{U � 1\ CITYILP �`�(� t I �o JIUD <br /> '7 1r� <br /> CROSS STREET_�A {D ✓A R V� APN PARCEL SIZE LAND USE APPUCAT10N#1�) m <br /> OWNER NAME S Cl APHONE ?CC' 0 01 k <br /> OWNER ADDRESS D <br /> ` r CITY/STATE/ZIP�� <br /> CONTRACTOR PHONE R%- J_�2/7 79 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP Gc Y- <br /> . C A G 5 L3 2 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS �CIITTY/$TATE/ZIP <br /> LICENSE =�C-57 -61 D-09 Other NUMBER a SS 5 EXPIRA71ON DATE -7-31 -10, <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Rang@ Section_ <br /> INTENDED USE )9,Domestic[Private Irrigation/Agricultural J Industrial -Water Quality Monitoring - Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Nam Loontact Nam or phone Number <br /> TYPE OF WORK New Well [i Replacement Well - Well Alteration/Modification i Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical •or bori gs <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 /> Proposed Well Depth '275 ft Excavation in diameter r Open Bottom -)(Gravel Pack/Gravel Size /A _ in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter (�7 in Thickness/Gauge/ASTM Schad C ;?(X i Steel ',Plastic ']Stainless Steel I1 Other <br /> Grout Seal Depth It 7 Neat Cement(94/b bag/5-10 gal water) Sand Cement 6 S sack mix17 gal water <br /> i Bentonite(20%solids) i i Other <br /> Grout Placement Method umped Free Fall 1 Other _!Retardant/.Accelerator(name) <br /> PEDESTAL Installed By Driller i_:Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width_L It Length � ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible-- Turbine -Other HP Pump Set_L ft Standing Water Level 1 GO 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 COMPENS LAWS. <br /> MI1 0UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9(53-7697 Q <br /> SIGNED �' c✓v 'C" TITLE \,1 t �C S DATE 4 27 1 b ` <br /> s <br /> N X\ <br /> �\ � O <br /> i RO�QP� <br /> DEP RTMENT U2E O Y yn <br /> Application Accepted By Date 0 Area ` Employee ID#� <br /> Grout Inspection By ) Date n SPECIAL Well Permit <br /> Pump Inspection By Date 2 b J WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Pertnft/ Invoice# WellID# <br /> Codes Info B Cash emitted Service Re uest# <br /> PD0 <br /> CISo s w—croag zob <br /> t -^ <br /> E D43-06 WFIL/PUMP PERMIT <br /> 4/30112 <br />