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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> S�L� Tom ' '� 7/ CITY/ZIP _ ( ��T 1�.. m <br /> JOB ADDRESS ��n / Z C <br /> CROSS STREET f / `" APN ` �I / �AARCEL SIZE BLAND USE APPLICATION# m <br /> ) cn <br /> OWNER NAME #4/-I"�W <br /> OWNER ADDRESS ` �(/ / ���Y�-31G / / _ CITY/STATE/ZIP <br /> CONTRACTOR / ^ /r/L` L'' !ice/J PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR ����/ �� ! _ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 't-61 1 D-09 H Other NUMBER n EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range__ Section___ <br /> INTENDED USEomestic/Private P Irrigation/Agricultural U Industrial f_, Water Quality Monitoring U Soil Sampling/Characterization <br /> 1 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORKja�FVew Well I i Replacement Well ❑ Well Alteration/Modification Fl Other <br /> 0 MonitoringWells #of wells 0 Soil Boring(s)s a of borings #of borings <br /> ( ) g( ) _ I_ Geotechnical <br /> n Out-Of-Service Well U Out-Of-Service Well Renewal Cl Cross-Connection Repair <br /> ew Pump r Pump Replacement 0 Pump Repair n Raise Well Casing <br /> WELL CONST TION <br /> Drilling Method U Mud Rotary ri Air Rotary 1 Auger U Cable Tool U Push Point U Other <br /> Proposed Well Depth Cl, j ft Excavation _�Z in diameter Open Bottom IV--ravel Pack/Gravel Size r in diameter <br /> I l Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in '1T?h ��Thickness/Gauge/ASTM Sched 4 7eOj Steel 51 Plastic '-1 Stainless Steel j Other <br /> Grout Seal Depth Neat Cement(94 lb bag/5-10 gal water) j and Cement sack min/7 gal water <br /> 1 Bentonite(20%solids) 1 Other <br /> Grout Placement Method umped - Free Fall : Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 'I Driller Xpump Contractor L1 Other <br /> Concrete Pedestal Dimensions:Width:4cft Length ft Thick in F Christy Box I-' Stove Pipe <br /> PUMP 1 ubmersiblel Turbine I I Other HP L Pump Set ft Standing Water Level � -- ft <br /> I HEREBY CEF(TIFY 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 /> MINI �iTf <br /> - U CE NOTICE REQUIRED FOR �I� PECTIONS- PLEASE CALL(209)953- 69 <br /> �V <br /> SIGNED f����--. TITLE Il�- DATEj Ad <br /> 1 � <br /> A � N <br /> LN' I' TA E 14 t <br /> 111111 111 <br /> DE FAHTiviEN USE vi� L7 <br /> Application Accepted By �� Date C Area J C Employee ID# �> <br /> Grout Inspection By Date G I SPECIAL Well Permit <br /> Pump Inspection By _ Date WAIVER Received <br /> Soil Boring Inspection By Date / Constructed Well Depth <br /> COMMENTS aa It/ 1 1191) .�.��_ <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> r-.1 it I <br /> 3 1 'ke <br /> r1 3 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />