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S Llt^ 0Y✓\ <br />%VELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTN '.NT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />NON-REFUNDABI P-RMJT. CAL _ 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />/I W <br />JOB ADDRESS ''� ���L-1'jU(.. �1! RD r-i1TY/ZIP `) 7 � /124`% y <br />CROSS STREET C. A'fVNYtA'?A 4r -iRPt' 1.r.LL..(��� PARCEL SIZE IOf ^'Z'tLAN.01 SE APPUCATQONf�E+ m <br />OWNERNAME '✓Pr (•)�1Co7fnPan0 A Ix LP Z3 —PHONE �n��yyt /�1'7 S� <br />OWNER ADDRESS �' O KJ o%� 717 -J —.-, _ C1TYlSTATFJZIP-r�S�^-Lt�l <br />CONTRACTOR 42 i.1 At.. � i �f� t^i l..;.L_L,�y (14 Irl. _Z.s� .- PHONE - h., l � ��ICA el Y / <br />CONTRACTOR ADDRESS - /"7't 1/�'PAja, %,_ 4, CITYISTATEIZIP TW77 1 bid+ ! <br />PHONE <br />SUBCONI1t TOR ADDRESS CITYISTATE/ZIPJ Q <br />LICENSE \\ G-57 C D-09 Olh ' NUMBER Y & 6 Z ExPIRAnoN DATE _ <br />GEOGRAPHICAL It1FORMATfON: Coordinates X 3t y a lf Y Z. : Y Township ,� Range �� Section � 4� <br />INTENDED USEmestic/Private _ inigalion/Agria turas industrial Water Quality Monitoring Soil Sampling/Characterization <br />Pub' Water System <br />If 61T64F <br />ttom Ownoc a er FYsWM NaMe o c. Mme of Phone NUmber <br />TYPE OF WORK New Well Replacement Well Well AiterabortModificado (other ,1 C- <br />I <br />Monitoring We s) # of wel > : Soil Boring(s) or twnngs Geotechnical # °r txnnps <br />Out -Of -Service V14 <br />Out-Of-Service Well Renewal Cross -Connection Repair <br />Punm RAnAir .l Raise Well Casino <br />(Drilling Method XMud Rotary Air Rota ALler CIVe Tool Push Point Other — <br />Proposed Well Depth O'0 ft Exca tion . 1 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing n di ater / Conductor Casing Depth It <br />Well Casing Diamat m Thickness/Gaugeh M Sched i Steel ` Plastic Stainless Steel Other <br />Grout Seat Depth_ ft it Neat Ce ten 41b bag/5-f 0 gal water) 7LSand Cement__sack mix17 gal water <br />Bentonit 120% solids) Other <br />Grout Placement Method I: umped :'; Free Fall Other .: Retardant! Accelerator (name) <br />PEDESTAL Instalted By Driller Pump C ntractor Other <br />Concrete Pedestal "'Dimensions:` fidth ft ngth R Thick in i Christy Box Stove Pipe <br />PUMP Submersible "t Turbine ..: Other_ HP Pupip Set ft Standing Water Level R <br />I HEREBY CERTIFY THAT I HAVE PREPARED TH i APPLICATION AND T THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, r ND RULES AND REGULAVONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE IUCEISE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MI l UM ?t611i0UFj�ADVANC�E N(jT CE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED <br />'��,rp �(,� ��'•.•�'� TrrLE�4 .Zl _ DATE �� r <br />FixYMEN Q <br />RECEIVE <br />viz <br />U <br />I DEQ � <br />EP RTMENT U E NLY <br />� }OAOUtNCo Ua�v - ,�j <br />E)NIRDFpART10` Application Accepted8 Date Area / Employee ID#�I <br />HF�TM i Grout Inspection By Date PECIAL Well Permit <br />Pump Inspection By Date I_ WAIVER Received <br />Soil Boring <br />COMMENTS J' <br />-+i ce-7 <br />Date <br />Constructed Well Depth <br />:A iAL [lakTH <br />17�l/.6 <br />PE SC Received _ Amount Date Permitt Invoice* WelliD# <br />Codes info By as Remitted Service Request # <br />EHD 43-M <br />4130/12 <br />EHD 43-M <br />4130/12 <br />