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� 0 �rni�igl SCUn 5(l�(l� 1'►� <br /> � - WELUPUMP PERMIT <br /> SAP!.i0A0UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> KION-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �' cn <br /> JOB ADDRESS 91 CITY/ZIP G <br /> CROSS STREET <br /> API [lX 7 (/ PARCEL SIZE F LAND USE APPLICATION# m <br /> 2 - I qI I N <br /> OWNER NAME otoop PHONE <br /> OWNER ADDRESS ( CITY/STATE/ZIP� <br /> CONTRACTOR PHONE�� X141 l <br /> CONTRACTOR ADDRESStaLIZ CITY/STATE/ZIP� f�/ � <br /> SUBCONTRACTOR /\ IPHONE <br /> 09,-7-2 /S` <br /> SUBCONTRACTOR ADDRESS /'0 go J� J " ITY/STATE/ZIP I( _ <br /> LICENSEVJC-57 1 i D 9 i Other NUMBE ION DATE'] C 6 ] 0 [ <br /> GEOGRAPHI AL INFORMATION: Coordinates X Y Township Range Section <br /> [LNENDEDUSE fU Domestic/PrivateIrrigation/Agricultural ❑ Industrial ; Water Quality Monitoring U Soil Sampling/Characterization <br /> 11 Public Water System <br /> If different from Owner: Water System Name ontact ameame one Number <br /> TYPE OF WORK ❑ New Well is Replacement Well 0 Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of wells E Soil Boring(s) If of borings E Geotechnical #of borings <br /> ❑ Out-Of-Service Well U Out-Of-Service Well Renewal 1i Cross-Connection Repair <br /> New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method if Mud Rotary ❑ Air Rotary i, Auger E Cable Tool U Push Point ❑ Other <br /> Proposed Well Depth qaU ft Excavation �_ in diameter Open Bottom 0 Gravel Pack/Gravel Size Mid in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter 11 in Thickness/Gauge/ASTM Sched 9-00 U Steel V Plastic E Stainless Steel ❑ Other <br /> Grout Seal Depthft 1 Neat Cement(94 lb bag/5-10 gal water) if Sand Cement /d• sack mix/7 gal water <br /> Bentonite(20%solids) �1 Other <br /> Grout Placement Method 0 Pumped =1 Free Fail n Other 17 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 7 Pump Contractor ❑ Other <br /> Concrete Pedestal 'Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible[; Turbine I; Other s 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 /> WORK S COMPENSATION LAWS. <br /> MFM 2 O ADVANCE NOTICE REQUIRED FOf INSP TIONS - PLEASE CALL(209F -7 97 <br /> SIGNED TITLE DATE <br /> tot <br /> rA <br /> u <br /> 15 ''n M f <br /> H nFPARTMFNT IrR_ F nuiY <br /> Application Accepted ee� ,Date 1 Area Employee ID# � <br /> n <br /> Grout Inspectio Date ❑ SPECIAL Well Permit <br /> Pump Inspection By _ _ Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date C nstructed Well Depth ft <br /> COMMENTS LGA_ZL 1 <br /> PE SC Received ChecAmount Permit/ <br /> Codes Info B s Remitted Date Service Request# Invoice# Well ID# <br /> 3(c� 0U D 3 3 °° �l��I� y�Do� 3 W F6ON 1 <br /> yE5 L4 DU 38 I <br /> EHD 4306 WELL/PUMP PERMIT <br /> 4130/12 <br />