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6W - 3�3a 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)953-70697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /� ,t/" V�. CITY/ZIP �/r/�; m <br /> D <br /> CROSS STREET APN O _5," 2J D^ 3/ PARCEL SIZE +1' LAND USE <br /> , �267 APPLICATION If <br /> S 7�0 <br /> �� [/CJd C�/„ y <br /> OWNER NAME PHONE l 2_7— <br /> OWNER ADDRESS /�/��� CITY/STATE/ZIP <br /> CONTRACTOR PHON <br /> A) <br /> CONTRACTOR ADDRESS �v / CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STZZAT]E21P <br /> LICENSE ><`C-57 I C-61 11D-09 I Other NUMBER - �.JD EXPIRATION DATE �-O� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private 1 Irrigation/Agricu!tural Industrial Water Quality Monitoring ;I Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ,7'Tdew Well replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> /ANew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method >47Mud Rotary Air Rotary i Auger Cable Tool Push Point i Other <br /> Proposed Well Depth 2 ?10 ft Excavation /), in diameter 1 1 Open Bottom Gravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched),00 1 Steel Plastic I Stainless Steel 1 1 Other <br /> Grout Seal Dept ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement ,�() 3 sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method s*�umped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By XDriller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP )(Submersible I Turbine I Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORI:!NANCES, STATE LAWS;, AND RULES AND REGULATICNS. I ALSO CERTIFY THAT IIAY PEQUIRED 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 /> MINIMLJM 2.4 HOUR ADVANCE NOTICE REQUIRED FO((�'R,, INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED '"� TITLE aAj/.&– DATE <br /> U <br /> G <br /> 4 <br /> _71 11 <br /> VU <br /> 16 <br /> 0 o�N�l <br /> DEPARTMENT USE ONLY HALT <br /> Application Accepted By ate Area Employee ID# <br /> Grout Inspection Date ❑ SPECIAL Well Permit <br /> runrip Insper..tion R� _ Daie / ❑ WAIVER Received <br /> Soil Boring Inspection By ` Date Constructed Well Depth _ ft <br /> COMMENTS OL ,>w <br /> i <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> iJ n 52 1411� <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30;12 <br />