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WELUPUMP <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />PERMIT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95241209) 4 <br />IVUI4-r1t:FUNUAbLh YtHMIT k;ALL (ZU9) 993-169/ FOR INSPECTIONS <br />4700 ni�s�r �. � a <br />JOB ADDRESS G ' ` CITY/ZIP '� � <br />CROSS STREET W u U P��� APN 1) 73— 7A PARCEL SIZE •,7 LAND USE APPLICATION # <br />OWNER NAME �� m w� V lT eed' h& PHONE l D ! C <br />OWNER ADDRESS / V"-� I. CITY/STATE/ZIP I eIr <br />_p,�A� <br />CONTRACTOR /'`Q�� I S �� % PHONE��2 /'Q <br />CONTRACTOR ADDRESS L ` 1. 4 I IRO CITY/STATE/ZIP , r(ffJ _` �1 r <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP r <br />LICENSE Y4"-57 1 C-61 D-09 Other NUMBER 8 Z EXPIRATION DATES L •z <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE I Domestic/Private rrigation/Agricultural Industrial I I Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone um er <br />TYPE OF WORK nNew Well IReplacement Well Well Alteration/Modification Other <br />Monitoring Wells) # of wells Soil Bori# of borings <br />ngs) <br />Out -Of -Service Well Out -Of -Service Well Renewal <br />Geotechnical a of borings <br />Cross -Connection Repair <br />INew rump rump meplacemenr rump Repair liaise wen Gasing <br />WELL CONSTRUCTION <br />Drilling Method X Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />a <br />Proposed Well Depth QC ft Excavation .20 _ in diameter Open Bottom Gravel Pack/Gravel Size G in diameter <br />I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter,[ in Thickness/Gauge/ASTM Sched _200 i Steel 601astic I Stainless Steel Other �. <br />Grout Seal Depth rT�' ft 1 1 Neat Cement (94 lb bag/5-10 gal water) Xand Cement -10,3 sack mix17 gal water <br />BeaierdY solids) 1 1 Other <br />Grout Placement Method :>QPumped l Free Fall I Other Retardant / Accelerator (name) <br />PEDESTAL Installed By i Driller I Pump Contractor I Other <br />Concrete Pedestal 1 Dimensions: Width ft 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 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953.7697 <br />f <br />SIGNED ���- I^��J� TITLE t.-1 he" DATE � " / _/b <br />rN <br />m <br />D <br />v <br />v <br />m <br />m <br />to <br />DEPARTMENT USE ONLY <br />Application Accepted qBy#r <br />Date Area 4r �L Employee ID# <br />Grout Inspection Date la�,��'_ ElSPECIAL Well Permit <br />Pump Inspection Date ❑ WAIVER Received <br />Soil Boring Inspection By <br />COIF MENTS Csrovl- in <br />go <br />Date <br />Constructed Well Depth <br />5u sno.l UCitis 10. <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit! <br />Service Request # <br />Invoice # <br />Well ID# <br />31 <br />( L> <br />30 <br />3til <br />�.� I� <br />5�0 ']yam <br />WPoo3Wg61 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />