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{�`,� WELUPUMP PERMIT <br /> j:+IQ JO AOUIN COUNTY tNVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA?ELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> MIN-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIR S 1 YEAR FROM DATE ISSUED <br /> rn <br /> Jos ADDRESS es�• t�� 'I�� • CITY21P SZZa mCROSS STREET�C� PARCEL SIZE LAND USE APPLICATION It 70 <br /> OWNER NAME /< --�/`�C_l � PHONE I <br /> r <br /> OWNER ADDRESS ^�/� f CITY/STATE/ZIP <br /> CONTRACTOR r `6S`= '—�C l� PHONE Z 3• 1/7 L <br /> CONTRACTOR ADDRESS P0 ` CITY/STATE/ZIP`�/ �.l' ✓��l�f/� u��J 7/ <br /> SUBCONTRACTOR XI/r-C "-"f_ PHONE r �r ✓ '� ` <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE <C-57 C-61 D-09 Other NUMBER 1 41; EXPIRATION DATE ✓ -7 - 6- JO <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE i Domestic/Private >4rrigation/Agricultural Industrial I Water Quality Monitoring Soil Sampling/Charactetation <br /> Public Water System_ <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK <New Well replacement Well Well Alteration/Modification I Other <br /> I Monitoring Well(s) #of wells i Soil Boring(s) #of borings I Geotechnical #of borings <br /> I Out-Of-Service Well i Out-Of-Service Well Renewal 1 I Cross-Connection Repair <br /> -Z-'New Pump I Pump Replacement i Pump Repair I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methodsr::.MUd Rotary i i Air Rotary I Auger I Cable Tool I Push Point I Other <br /> Proposed Well Depth�ft Excavation / in diameter Open Bottom 1;eiavel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter/b— in Thickness/Gauge/ASTM Schede 3-QSteel Plastic i stainless Steel Other <br /> Grout Seal Depth �6 ft Neat Cement(94 lb bag15-10 gal water) >,-.and Cement lC��e5 sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped 1, Free Fall Other Retardant/Accelerator(name). <br /> PEDESTAL Installed By ;-<briller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ! ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP ,/Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> 1 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 %-O;-,.TRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> MIN�4 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209))+953-7/697_ <br /> SIGNED TITLEVl�/f G%� DATE 6, <br /> i <br /> ro <br /> r <br /> 4 <br /> 10 <br /> DEPARTMENT U E NLY A <br /> Application Accepted Date 0 Areas/ Employee ID# <br /> Grout Inspection B ^� Date SPECIAL Well Permit <br /> Pump Inspection By Date U l WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Request# Invoice# Well ID# <br /> 110 <br /> v 01 sP 7 a ,3 0 <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4/30/12 <br />