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r, <br /> t <br /> WELVPUMP PERMIT <br /> ✓ ! <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT - 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> LJOB ADDRESS < � (C' / Crit IP �Y <br /> a <br /> �7 }� o <br /> CROSS STREETG �JL / f/ AP �7�� /C��� Lf'ARCEL SIZE LAND <br /> LAND USE APPLICATION# <br /> OWNER NAME 1(/e�lG,U !/(���CJ�! �a 1 ,7T—�Ph'TT PHONE.&-sp— <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR _�/l,[/7't L'I//iAAPYy f�[�/1'2 PHONE <br /> CONTRACTOR ADDRESS /• � C/\ CITY/STATE/ZIP /'�/f/P✓ 't✓�k C" �S�y <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrrWSTATE/ZIP t <br /> LICENSECS7 L C-61 U D-09 U Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private :1 Irrigation/Agricultural ❑Industrial 7 Water Quality Monitoring C Soil Sampling/Characterization <br /> U Public Water System <br /> If dffemnt from Owner. WaterYSWM NaMe ContaCt NaM9_o-rPlio-n­e1Tu—m5e-r— <br /> TYPE OF WORK ) New Well L Replacement Well U Well AlterationlModification U Other <br /> /❑"Monitoring Well(s) #of wells O Soil Bodng(s) #ofborings D Geotechnical #ofborings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> U New Pump L Pump Replacement U Pump Repair U Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method-A Mud Rotary C Air Rotary C Auger D Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 2Z,0 ft Excavation _in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter <br /> rl Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched rT Steel ❑Plastic rl Stainless Steel ❑Other <br /> Grout Seal Depth d,) it C Neat Cement(94 lb ba¢5-10 gal water) ❑Sand Cement sack mixR gal water <br /> 1(Bentonite(20%solids) L Other <br /> Grout Placement Method)k Pumped ❑Free Fall C Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 7 Driller C Pump Contractor 7 Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stave Pipe <br /> PUMP ❑Submersible]Turbine C Other HP Pump Set it 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. 1 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 /> I IMUM 24 HOU AN NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Q�1'r LLE; DATEPT�V' <br /> E cHT <br /> NUN <br /> RTj yFNT <br /> ARS ENT U E O LY yy' /J� <br /> Application Accepted By Date Area Employee <br /> Employee ID# <br /> Grout Inspection By Qate ❑ PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring In action By Date Constructed We th ft <br /> COMMEX� � �� t <br /> NTS / <br /> PE SC Received. Amount Date Permit/ Invoice# WeIIID# <br /> Codes Info C Remitted Service R uest# <br /> I$ D��J67a <br /> MOT <br /> 3 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4130/12 <br />