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WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NODI-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS { ' �1 CITY/ZIP / Y�/� / ��� m <br /> D <br /> CROSS STREET /J/4CJ 41W APN A�!✓ /(V 0 PARCEL SIZE LAND USE APPLICATION# n <br /> m <br /> cn <br /> i ,� <br /> OWNER NAME I CtJJ L � PHONE <br /> OWNER ADDRESS �/l C��� CITY/STATE/ZIP C� <br /> CONTRACTOR 7 � �L PHONE <br /> CONTRACTOR ADDRESS r-0 CITY/STATE/ZIPZI & r.1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE >14-57 C-61 _ D-09 Other NUMBER:' elf EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private 5(rrigation/Agricultural D Industrial Water Quality Monitoring u Soil Sampling/Characterization <br /> I I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK, eW Weil I Replacement Well I Well Alteration/Modification I I Other <br /> I 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 - tion Repair <br /> ><Lew Pum C Pump Replacement I I Pump Repair I Raise Well Cas <br /> WELL CONSTRUCTION <br /> Drilling Method�'Wlud Rotary L Air Rotary I Auger i 164lle Tool Pus Point Other <br /> Proposed Well Depth ft Excavation in diameter O n Bottom ravel ack/Gravel Size in diameter <br /> Conduc Casing in diameter / Condu for Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched r- Steel astic S inless Steel Other <br /> Grout Seal Depth j ft L Neat Cement(94 Ib bag/5 10 1 water) d Ceme v. sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method><Pumped Free Fall t Retardant/Accelerator(name) <br /> PEDESTAL Installed By I_I Driller i Pump Co actor I Other <br /> Concrete Pedestal Dimensio s:WidtilI 41 Lengthft Thick in Christy Box I, Stove Pipe <br /> PUMP olgl:jubmersible I Turbine I Ot r H Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS AP LICATIO AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAW , AND R ES A REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNI CONTRA R STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI M 24 HOU ANCE NO Cl REQUIRED FOR INSPECTIONS- PLEASE CALL(209) 953-7697 J <br /> SIGNED — <br /> 1`F1�LE/���if� DATE �� <br /> 1 <br /> G <br /> T <br /> SA <br /> F Vurr <br /> IA1 C <br /> DEPARTMENT USE ONLY <br /> Application Accepted By / Date TO Area 4Lj Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring I spection By A Date Constructed Well Depth ft <br /> COMMENTS r <br /> PE SC Received Amount Permit/ <br /> Codes Info B Remitted Date Service Request# Invoice# Well ID# <br /> 7A �� / M 0�- <br /> 3 � J 3SK 00 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />