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WELUPUMP PERMIT SP.N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED L f ?572S m L QC1�JOB ADDRESS CITY21P D CROSS STREETr�I i- TLiU. Y�RL�APN ® —� :EL SIZE LAND USE APPLICATION# m c} OWNER NAME 0r �� dd PHONE�Cr�S 0-Jm(^'- N OWNER ADDRESS U CITY/STATE21PQt7y15- CONTRACTOR }U imR)rns- '1`u Jyyy,cb- tic-, PHONE CONTRACTOR ADDRESS aoo { Q SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE KC-57 1 C-61 J D-09 11 Other NUMBER /�_ EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section a INTENDED USE U Domestic/Private 11 Irrigation/Agricultural VQnduStrial Ci Water Quality Monitoring 0 Soil Sampling/Characterization I I Public Water System Qr2SSrq Qje4 i If different from Owner: Water System Name Co t Name or Phone Number TYPE OF WORK ;141ew Well X-Replacement Well 0 Well Alteration/Modification ❑ Other 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair L. New Pump [t Pump Replacement 0 Pump Repair 71 Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary 0 Air Rotary ❑ Auger Ll Cable Tool U Push Point X Other R-e1V.,rSP- Qr) 1 L,4-- Proposed Well Depth SOD Excavation 29 in diameter ❑ Open Bottom X'Oravel Pack/Gravel Size jinn td�iameter AConductor Casing�in diameter / Conduc or Casing Depth I DO I ft 90,W Fa—k, Well Casing Diameter f(� in Thickness/Gauge/ASTM Sched"� t'Steel 0 Plastic C Stainless Steel 0 Other Grout Seal (depth_ JW ft Neat Cement(94 Ib bag/5-10 gal water) X Sand Cement k— sack mix/7 gal water LI Bentonite(20%solids) Other �r f k ��I /'T9'dw(:c f r &,,mo i Grout Placement Method D(Pumped ❑ Free FaYI__. _F Other L Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller pump Contractor 0 Other Concrete Pedestal %Dimensions:Width It Length ft Thick in ❑ Christy Box n Stove Pipe PUMP ❑ SubmersibleU Turbine f; Other HP Pump Set It Standing Water Level It I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS, MINIMUM 24 HOUR ADVANCE NOTICE REQU OR,IlNSPECTIONS-PLEASE CALL (2091)953-7697 SIGNED �� TITLE " ' DATE {o Z) 17 D1 z O h / O d -14 fl'I I I L I I I i 11i I I 11ji I I DEPARTMENT USE ONLY Application Accepted By ��atc Area—�d Employee ID#1� C, Grout Inspection By Date = ❑ SPECIAL Well Permit 77 Pump Inspection By _. Date ❑ WAIVER Received Soil Boring 1r�s pe tion By °Date Constructed Well Depth ft CQMMENTS_I CK- ti` Y A PE SC ReceivedF--(--7C—he ck# Amount Permit/ Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# 11-171 !_HD 43-06 WELL/PUMP PERMIT