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60 <br /> WELUPUMP PERMIT 9/ L-- zA� <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT f- CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> C <br /> JOB ADDRESS -i 3�= CITY21P S <br /> �, aL D <br /> CROSS STREET G. /� APN !O 3 I / l/D 7 PARCEL SIZE LAND USE APPLICATION# m <br /> OWNER NAME ,fes y� PHONE _U -) <br /> OWNER ADDRESS S.X/I � CITY/STATE/ZIP ` �-< <br /> L <br /> CONTRACTOR ' 9 PHONE3:? /-- Ltir_ <br /> CONTRACTOR ADDRESS/ V I�Q� CITY/STATE/ZIP 4�40A& <br /> Jr <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> –y 7 <br /> LICENSE or .Y /C-57 C-61 D-09 I Other NUMBER i�� EXPIRATION DATE — <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name ontactName or Phone Number <br /> TYPE OF WORK �itew Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) If 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'r-Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Deptl��ft Excavation Z'2— in diameter Open Bottom ravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter -C � <br /> in Thickness/Gauge/ASTM Schad�`` ISteel XPlastic Stainless Steel Other <br /> Grout Seal Depth /c27 ft Neat Cement(94/b bag/5 10 gal water) >eSand Cement' �T_sack mbd7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method s[pumped Free Fall I Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By >4)riller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP 54ubmersibw Turbine Other HP� Pump Set ft Standing Water Level It <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 IVUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-76j97 <br /> SIGNED ��� TITLE ©tom, . DATE7-2,3-/4 <br /> /O <br /> i <br /> v <br /> 4 <br /> O <br /> 16 <br /> 41 <br /> DEPARTMENT USE ONLY U <br /> Applicaticn Acceoted By - nate �� n.r�a l �. :�,s` �/Oj�d s <br /> Grout Inspection By - Date Z ❑ SPECIAL Well Permit t <br /> Pump Inspection B Date ❑ WAIVER Received <br /> Soil Boring L s ection,B Date C nstrycted Well epth ft <br /> COMM NTS f <br /> 17 <br /> PE SC Received Check#/ Amount Date Permit/ I11 <br /> nvoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> 7 i�/ e Ob -7S _ � I)0 2lq Q0 0 -05 <br /> SL4 <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4/30/12 <br />