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& . WELUPUMP PERMIT F ✓" <br /> SAN JOAQUIN 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 /> JOB ADDRESS I �J<s PAPt'56A-) 'V CITY/ZIP cj7 <br /> I 1o c 1nr0" C-P 95Z %5' <br /> CROSS STREET <br /> T/lcc�Lf Z{o APN v1 V / 0 d PARCEL SIZE LAID USE APPLICATION# <br /> S'TE✓fin ��`� PHONE 9617-Y_0_& y <br /> OWNER NAME c J <br /> OWNER ADDRESS �PAPi%SOt3 12e-I CITY/STATE/ZIP ✓ COG A -rC'A Ley/* !25--213- <br /> 7/Z! <br /> CONTRACTOR �3 1'1/) �(Ie'6 FYIC- PHONE �� /5'/ / <br /> � '101,7 <br /> CONTRACTOR ADDRESS l?,,,o( Z'3 217 CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONEZCW -772 275'7 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE )(C-57 C-61 D-09 Other NUMBER /�7�� EXPIRATION DATE P' 3 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private I Irrigation/Agricultural I Industrial I Water Quality Monitoring 1 1 Soil Sampling/Characterization <br /> Public Water System _ <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK XNew Well Replacement Well Well Alteration/Modification Other FlEkr <br /> I Monitoring Well(s) #of wells i Soil Boring(s) #of borings I Geotechnical #of/rborings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair ��L <br /> New Pum Pum Replacement Pum Repair Raise Well CasingSA ?018 <br /> WELL CONSTRUCTION ENV/� /M COD <br /> Drilling Method VMud Rotary I Air Rotary I Auger l Cable Too] I Push Point I Other H��TH D NMF�TANIY <br /> Proposed Well Depth ft Excavation in diameter Open Bottom !y Gravel Pack/Gravel Size in die - nr <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter__�p in Thickness/Gauge/ASTM Sched / Steel /111 Plastic Stainless Steel Other <br /> Grout Seal DepthZ4no ft I Neat Cement(94 Ib bag/5-10 gal water) I Sand Cement sack mix/7 gal water <br /> I Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By X Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in I Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP 1 '12— Pump Set /gt7 ft Standing Water Level �- ft <br /> I HEREBY CE TIFY 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 /> MINIMU/ R ADVANCE N REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED TITLE�� �C �4 DATE 7—1 <br /> I it <br /> Dr <br /> V <br /> EPARTMENT USE ONLY �/� <br /> Application Accepted By Q� Date �� Area C Employee ID# " n y <br /> Grout Inspection By f Date — El SPECIAL Well Permit / <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Insp tion By Date Constructed Well Depth ft <br /> COMMENTS 01) C c "4 r � SP )'( .41nKI IIIA t' <br /> PE SC Receivedheck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> it; I 0 �Z/ <br /> H3Y0 OS U <br /> y Icl 1 143- 1 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />