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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 (2U9) 953-769/ FOR INSPECTIONS C/lrimr-J I T tAh rnvm L104 r_ laavcv <br />JOB ADDRESS <br />SC <br />Info <br />21< <br />CITY/ZIP <br />Amount <br />Remitted <br />CROSS STREET <br />OWNER NAME <br />(/,v <br />¢ ! <br />-6 99 9 1 9 ®6 2— <br />D� <br />�e-=' <br />PARCEL SIZE 10, T <br />LAND USE APPLICATION ## <br />PHONE Z_ < ly� <br />OWNER ADDRESS/�f <br />CONTRACTOR <br />r <br />/�. <br />G'� ; <br />/ <br />CITY/STATE/ZIP <br />— <br />PHONE <br />CONTRACTOR ADDRESS <br />6/�L���-�( <br />woo coy <br />CITY/STATERIP <br />3/f/�� �✓/! < SZ`—� <br />3 73 <br />o <br />'c-"1/ <br />SUBCONTRACTOR <br />IL/ <br />3 <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />;"'° <br />�/ie <br />CITY/STATE/ZIP <br />LICENSE -57 <br />-61 i 1 D-09 <br />[l Other NUMBER F ( <br />EXPIRATION DATE T <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE Domestic/Private CO Irrigation/Agricultural 0 Industrial C; Water Quality Monitoring U Soil Sampling/Characterization <br />n Public Water System <br />If different from Owner: Water System Name-------- Contact Name or Phone Number <br />TYPE OF WORK n New Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings C Geotechnical # of borings <br />U Out -Of -Service Well U Out -Of -Service Well Renewal U Cross -Connection Repair <br />/New Pump [' Pump Replacement ❑ Pump Repair U Raise Well Casing <br />Drilling Method A Mud Rotary ❑ Air Rotary ❑ Auger U Cable Tool U Push Point ❑ Other <br />Proposed Well Depth�ft Excavation in diameter !7 Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />Li Conductor, Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter /Fi in Thickness/Gauge/ASTM Sched e <br />4 U Steel �lastic C Stainless Steel U Other <br />Grout Seal Depth_,�o ft ['; Neat Cement (94 lb bag/5-10 gal water) Sand Cement /&41 sack mix/7 gal water <br />J Bentonite (20% solids) 1 Other <br />Grout Placement Method 114pumped ❑ Free Fall Fj Other U Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller XPump Contractor ❑ Other <br />Concrete Pedestal -1 D' ensions: Width ft Length ft Thick in LI Christy Box F. Stove Pipe <br />PUMP Submersible[; Turbine I; Other HPA_y j=_ Pump Set ((0�0 It Standing Water Level i 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 />A _ l) 1.1 <br />e <br />T <br />m <br />D <br />0 <br />0 <br />n <br />m <br />to <br />DEPARTMENT USE ONLY <br />Application Accepted B Date '2 <br />Or -.,,it Inspection B — Date <br />Pump Inspectio Date L <br />Soil Boring Inspection By -„ Data, <br />Area 1 `q Employee ID#C� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constyucted )illell Depth _ A ft <br />6') <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/Invoice <br />Service Request # <br /># <br />Well ID# <br />93V <br />( 80 <br />q 37 <br />3&j d" <br />`_- ou <br />SRce 19�2n <br />woo coy <br />9 a <br />3 73 <br />o <br />'c-"1/ <br />;"'° <br />�/ie <br />Skoo7sS2 <br />�0��3�� <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />