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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 w <br /> -1 Z-t: m <br /> f CITYI2:IP <c� l�''-T D <br /> JOB ADDRESS u '] !✓ t7 <br /> L �1 0 <br /> CROSS STREET 46 LL,e h L y APN 2,1-t 1 7 4 6c-I PARCEL SIZE a• LAND USE APPLICATION# m <br /> OWNER NAME ;'�f i�V [r471i+ I�rLD 'rf PH <br /> _I <br /> OWNER ADDRESS / r ) /� { •T- %� <br /> ( {4 (fir—_L-(/ ,�--'J 1 PHONE I>C �- -/t% r U <br /> CONTRACTOR f r h _7 <br /> CONTRACTOR ADDRESS S COSI_ ��P✓ �/ CINISTATEIZIP H <br /> PHONE <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS CIITY/STATE/ZJP <br /> LICENSE C-57 -;C-61 D-09 _Other NUMBER 7 t-'&%7&C i E%PIRATION DATE <br /> Y q( I <br /> GEOGRAPHICAL INFORMATION: COOfdlnates X �+U 'f l 1 l Z V f�7L 7 Township�_ Range 4= Section 3_'t <br /> INTENDED USE DOmeslltlPnvate Inigation/Agricultural _:Industrial ..Water Quality Monitoring ._ Soil Sampling/Characterization <br /> Public Water System a er ys m ame on a Name or one u r <br /> If different from Owner: <br /> TYPE QF WORK �LNew Well Replacement Well Well Alteration/Modification _Other *ofbonngs <br /> #or borings _ <br /> Monitoring Wells) #of wells _ Soil Borings) Geotechnical <br /> _Out-Of-Service Well Out-Of-Service Well Renevral 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�t"; ft Excavation�in diameter _.Open Bottom �CGravel Pack/Grave <br /> l Size Y✓l+n9ftkliameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_]12C in Thickness/Gauge/ASTM Sched S^ 4 I Steel kPlastic Stainless Steel .Other <br /> Grout Seal Depth A41C It Neat Cement(941b bag/5-10 gal wafer) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) -Other <br /> Grout Placement ethod'}Pumped _Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller _Pump Contractor _ Other <br /> Concrete Pedestal Dimensions:Width It Length ft Thick in Christy Box _Stove Pipe <br /> PUMP Submersible Turbine 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 ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MV 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 /> MINIMU 4 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209))953-7697 <br /> SIGNED �i TITLE C. t" C% DATE + Z/t-7/ <br /> ao,S2�16 <br /> 04M�U <br /> De�R�FNT <br /> PA TM E NT USE bNLY <br /> tr�P1 <br /> Application Accepted By Date Z (� Area Employee ID# b V t/�� <br /> Grout Inspection By Date ❑ SPECIAL WBII Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By ate / bnstructed W II Depth It <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date P rmitt voice# Well ID# <br /> Codes Info B Cash <br /> W=LL(PUMP PERMIT <br /> EMD 7n-ae ,(—/- 5— <br /> .ID +.Vrr/•J <br />