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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 <br />JOB ADDRESS �6[ <br />CROSS STREET <br />OWNER NAME <br />CAL <br />.(2U9) 953-7697 FOR INSPECTIONS � I-ArlMr-0 I T tAH rnulVI WA i c r00uw <br />L�fQn (� CITY/ZIP <br />{) jt/%� 60 2__ PARCEL SIZE —LAND USE APPLICATION # <br />/V PHONE &�'e Z— <br />OWNER ADDRESS CITY/STATE/ZIP <br />PHONE / � _ '5�/ �" <br />CITY/STATE/ZIP d//l y Z!/Of I? <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR J9 1o''0 /11 ���17 PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE <br />1 iI D-09 [1 Other <br />NUMBER <br />CITY/STATE/ZIP <br />EXPIRATION DATE b'V-3 -3 I <br />GEOGRAPHICAL INFORMATION: Coordinates X Y_ Township Range Section <br />NTENDED USE Domestic/Private ri Irrigation/Agricultural 0 Industrial C; Water Quality Monitoring U Soil Sampling/Characterization <br />rl Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK n New Well VReplacement Well ❑ Well Alteration/Modification 0 Other <br />U Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings 0 Geotechnical # of borings <br />0 Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />)(New Pump C' Pump Replacement ❑ Pump Repair [I Raise Well Casino <br />Drilling Method A Mud Rotary ❑ Air Rotary r] Auger ❑ Cable Tool ❑ Push Point 0 Other <br />Proposed Well Depth ZX ft Excavation in diameter 0 Open Bottom i� Gravel Pack/Gravel Size in diameter <br />0 Conductor I Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter ZI- in Thickness/Gauge/ASTM Sched 44 '1 Steel .Mastic ❑ Stainless Steel 0 Other <br />Grout Seal Depth /Z ft Neat Cement (94 lb bag/5-10 gal water) /Sand Cement /&41:F, sack rnhd7 gal water <br />CI Bentonite (20% solids) r 1 Other <br />Grout Placement Method Oumped -i Free Fall 0 Other i' Retardant / Accelerator (name) <br />PEDESTAL Installed By r_1 Driller >fPump Contractor ❑ Other <br />Concrete Pedestal . D' ensions: Width ft Length ft Thick in 0 Christy Box 1! Stove Pipe <br />PUMP %Submersible 1 Turbine I ; Other HP _t JL 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 />MI ' H� / ANCE NOTICE REQUIRED FOR I SPEEJCTTIONS - PLEASE CALL (209) 95 7 97 <br />SIGNED Z TITLE R4'"' T/DATE <br />T <br />.i <br />m <br />D <br />v <br />O <br />M <br />M <br />rn <br />ur <br />DEPARTMENT USE ONLY <br />,application Accepted B Date <br />E?r,:at Inspection B Date 1 <br />Pump Inspectio Date L <br />Soil Boring Inspection By ,�, T Datq <br />Area � 1 Employee ID# 0 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />Al <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Well ID# <br />`112 iu <br />19�2(; <br />woo coy <br />y� <br />3 <br />e*C' <br />she i <br />hoc Sg2�i <br />o�sS2,6 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />