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WELUPUMP PERMIT /oo,& L-- 2-11�0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT fi CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ✓ .C- Rd CCITYIZIP m <br /> CROSS STREET L­157ej�.' C1 APN 1031q E <br /> ��l PARCEL SIZ - LAND USE APPLICATION If n <br /> OWNER NAMEZ <br /> �A Lys ��Z__VZ-A PHONE 9-� 7 �H ,/ ty/f <br /> OWNER ADDRESS S'Aogfig CITY/STATE/ZIP �7 <br /> CONTRACTOR � j c7 /PHONN;E�y 3 2 V--[L/< L� <br /> CONTRACTOR ADDRESS'e /(j� CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE or C-57 I C-61 I D-09 1 Other NUMBER J�7` ` S e-r EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private 1 Irrigation/Agricultural i Industrial Water Quality Monitoring 1 Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Na_m­e­_o_r_PTio6e Number <br /> TYPE OF WORK *-.New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> ew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method"�ud Rotary Air Rotary Auger Cable Tool Push Point i Other <br /> Proposed Well Dept!2__ 640 ft Excavation /2= in diameter 1 Open Bottom P4avel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_V_ in Thickness/Gauge/ASTM Sched 7—Ja i Steel >ZPlastic I Stainless Steel i Other <br /> Grout Seal Depth 100 ft i i Neat Cement(94 Ib bag/5-10 gal water) >Sand Cement,'149 sack mix/7 gal water <br /> I I Bentonite(20%solids) I Other <br /> Grout Placement Method Apumped I Free Fall i i Other i I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ,.driller I Pump Contractor I i Other <br /> I Concrete Pedestal Dimensions:Width 1 ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP 54ubmersiblel Turbine 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 LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI UM 4 VUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-76y97 <br /> SIGNED � TITLE DATE ` -2,8-/ <br /> i <br /> i <br /> ti <br /> 4Q <br /> w <br /> 0 <br /> r <br /> 1 1-12 <br /> CN <br /> IL <br /> w <br /> DEPARTMENT USE ONLY <br /> Apolicaticn Accented By _ . _ nafo � �� ^'�a l -� <br /> Grout Inspection By - Date Z ❑ SPECIAL Well Permit <br /> Pump Inspection B Date ❑ WAIVER Received <br /> Soil Boring Ir.:�pection-By Date C nstryctedWell/epth - ft <br /> COMMENTS �, <br /> y' v� <br /> let J <br /> ell <br /> PE SC Received Check#/ Amount Permit/Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> D l0 �c Zcxc' <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />