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WEL..UPUMP PERMIT <br /> SAN uOAQUIN rOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NOF-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �2 C/•"3 0 u"wo cj l m 6 CITY/ZIP � � ' j '/r � D <br /> ��[ /� ( o <br /> CROSS STREET / APN I D S '"� (�V PARCEL SIZE � ('�-OiAND USEyAPPPLICATION�># p <br /> OWNER NAME _`1:���I�,�' / Y<�Z SI I �, kdU (I PHONE �✓C�' �(/�'.S 7�U — N <br /> 95Z3 <br /> OWNER ADDRESS <br /> CONTRACTOR PHONJE <br /> �j <br /> CONTRACTOR ADDRESS I UQ✓�S Y,4 CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 :I D-09 [1 Other NUMBER`L.R_6;"Z EXPIRATIONDATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y _ Township _ Range Section <br /> INTENDED USE 1)Qomestic/Private t. Irrigation/Agricultural U Industrial [:i Water Quality Monitoring U Soil Sampling/Characterization <br /> I 1 Public Water System <br /> If different from Owner: VVater System Name contactName or Phone Number <br /> TYPE OF WORK New Well H Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of wells I; Soil Boring(s) of borings _ Geotechnical #of borings <br /> 0 Out-Of-Service Well 11 Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pum r' Pump Replacement Li Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method P' Oucl Rotary C Air Rotary I:, Auger U Cable Tool U Push Point ❑ Other <br /> Proposed Well Depth _'.�>.3-T ft Excavation ,17 in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> 11 Conductor Casing in diameter / in <br /> Casing Depth �ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched .2 kc, ❑ Steel XPlastic 1-; Stainless Steel ❑ Other_ <br /> Grout Seal Depth C D ft Neat Cement(94 Ib bag/5-10 gat water) ❑ Sand Cement sack mix/7 gal water <br /> ;<Bentonite(20%solids) I I Other <br /> Grout Placement Method umped -1 Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By �1 Driller XPump Contractor tl Other <br /> 7 Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box n Stove Pipe <br /> PUMP i-, Submersible! Turbine i; 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 L!CENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR"ADDV�AI�-E NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209))9/53-7697 <br /> SIGNED_ _L V' 1 �r�c C L py TITLE 1.,r'1 !�f r DATE % <br /> 1 <br /> cy E N <br /> .3 M <br /> i^ <br /> pu <br /> l l <br /> FW+ <br /> DEPARTMENT USE ONLY <br /> Application Accepted By 4 Date S " I Area / Employee ID# loGr <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspevectio (� t .Date Constr te/qlWell De7tchtft <br /> COMMENTS l <br /> " <br /> PE SC Received Chec amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> y3 Yv (,� 3��z 5 y 5/1 /, poa x`61.0 <br /> q 5 — <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />