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T_6'Ivth\ ffut^ 9l-H6 DiN <br /> WELUPUMP PERMIT <br /> SAN JOAGUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> O A 7 <br /> • JC- CITY/ZIP <br /> Joe ADDRESS ) — <br /> CROSS STREET_ _ r, I �67� l J (� PARCEL SIZE r I LAND USE APPLICATION# m <br /> y <br /> OWNER NAME � /LE�" PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP • �J <br /> CONTRACTOR /' •' T ft//� 'f'7� PHONE 47) <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP /y <br /> SUBCONTRACTOR —rCT� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 757 -61 n D-09 111'16y T1 1U Othef NUMBER EXPIRATION DATE I' <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring O Soil Sampling/Characterization <br /> U Public Water System <br /> If different from Owner. afar ystem ame ntact ame or one Number <br /> TYPE OF WORK Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) a of borings ❑ Geotechnical a of borings <br /> ❑ Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUefiON <br /> Drilling Method <br /> lud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Toot L) Push Point ❑ Other <br /> Proposed Well Depth ft Excavation IZ in diameter ❑ Open Bottom ravel Pack/Gravel Size '�- in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth K <br /> Well Casing Diameter/6- in Thickness/Gauge/ASTM Schad e.4 ❑ Steel-lk*lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth7920 It ❑ Neat Cement(94 Ib bag/5-f0 gal water) Sand Cement /Of sack mix/7 gal water <br /> ❑ Bentonite(20%solids) J Other <br /> Grout Placement Method umped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 11 Driller ❑ Pump Contractor ❑ Other <br /> ^. Concrete Pedestal ['Dimensions:Width_ft Length it Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP u1bmersible1j Turbine ti Other HP Pump Set__7=gV it Standing Water Level <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 PE SATION LAWS. <br /> MI 4 UIQ CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9513-76W <br /> SIGNED TITLE DATE <br /> 7 <br /> L 10 lb <br /> 1 1^11107 104 <br /> E <br /> Sq � o <br /> 4E � <br /> ��D-£ PARTMENT U,s� oNLY <br /> Application Accepted By;_ Y/Y/�lvv Date_qk11 II Area Employee Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS - --- <br /> PE Sc Received hec Amount Date Permit/ Invoice# Well ID# <br /> ['odea Info B as Remitted Service Request# <br /> 361 to 5kM75Z6-2b <br /> y3 ur' 7 <br /> WELL/PUMP PERMIT <br /> EHD 43-06 <br />