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WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)46&3420 <br /> NON-REFUNDABLE PERMIT CALL <br /> (2209 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS � �l CDY/ZJP <br /> CROSS STREET APN L-�'31$07-6 <br /> _PARCEL SUE I,S LANG USE APPLICATION d <br /> OWNER NAMEV 1 OT V1. C-Y(�.`Py_(`_ �-j4 PHONE <br /> OWNER ADDRESS Alum' <br /> -2 C"ISTATF/ZW S ktfz)IIJt11- <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS C"STATEIZIP <br /> SUBCONTRACTOR X412 MQ`( Citg M RC7I1 J PHONE <br /> SUBCONTRACTOR ADDRESS T Dbox �,�Tl CRYSTATE/LP <br /> LICENSE 'J C-57 I:C-61 U D-09 l:Other NUMBER EAPmAnDN DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range_ Section_ <br /> INTENDEDUSE IDomestic/Prtvate -I InigatiolvAgdcultural ii Industrial I.Water Ouelity,Monitoring , Soil Sampling/Charecledzatlon <br /> Public Water System <br /> II d�Renm nom Ovmen r yown correct Nrne w Ithatt.Rubber <br /> TYPEOF WORK C New Well [i Replacement Well ❑Well Alteration/Modification I:Other <br /> C Monitoring Well(s) d of wells :)Soil Boring(s)__ f of twaPys L Geotechnical a el w.nae <br /> L!Out-Of-Service Well X"ut-OI-Service Well Renewal J Cross-Connection Repair <br /> C New Pum I Plan Replacement :.I Pump Repair J Rain Weil Casln <br /> WELLCONSTRUCTION <br /> Drilling Method c Mud Rotary r Air Rotary F1 Auger _;Cable Tod it Push Point C Other <br /> Proposed Well Depth ft Excavation in dameter :r Open Bottom t Gravel PacWGravel Size in diameter <br /> D Conductor Casing in diameter / Conductor Casing Dept ft <br /> Well Casing Diameter_in Thickness/Gouge/ASTM Schad__ 'I Steel ;.Plastic I Stainless Steel Other <br /> Grout Seal Depth—ft C Neat Cement(94 lbba95-10 go/water) .I Sand Cement sack n9d7 gal water <br /> I Bentonite(20%solids) C Other <br /> Grout Placement Method C Pumped Free Fall I'Other r Retardant I Accelerator(name) <br /> PEDESTAL Installed By I:Driller Pump Connector I Other <br /> 7 Concrete Pedestal Dimensions:Width—ft Length ttThlck in 1 Chrinl Boz ,.Stove Pl <br /> PUMP L Submersible(1 Turbine .I Omer HP Pump Set.D 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 /> WORKERS COMPENSATION LAWS. <br /> M IMU H ADV OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209 953-7697 <br /> SIGNED TITRE DATE <br /> TIMM <br /> r <br /> lil,11111 hit <br /> . E.P.ARTMENT US ON L.Y I pr�_ <br /> Application Accepted By Date R ti�(� Area D Z`q 1 Employee IDs fi�(e"' <br /> �^ ` <br /> Grout inspection B- Date ❑ SPECIAL Well Permit <br /> Nmp I s4p%on By Date— ❑ WAIVER Received <br /> Sod Boring(Inspection By Data Constructed Well Depth H <br /> COMMENTS /t&t 'AOF 5iPLfeed;7� (,AS <br /> /�✓;'1/FYJY�Y'b'Y !fir <br /> PE SC Rxelved C / Amount Perm"/ invoiced Well IDN <br /> Codes Into B <br /> Ch <br /> flemiHe Data <br /> Service Re uaetd <br /> srP4 Jia los t.D <br />