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1041 WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 -(209)468.3420 <br /> NO"EFUNDABLE PERMIT CALL(2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ' Joe ADDRESS " "_ ""'`�'"' � � _ � CITYIZIP- f/� D <br /> 0 <br /> CROSS STREET C.r/- APN DoZ 0000V:7 PARCEL SIZE�O LAND USE APPLICATION# m <br /> OWNER NAME Q ILf f�c S6N PHONE"3 65- 3 o,3 o '^ <br /> OWNER ADDRESS Ina c CITY/STATLIZIP <br /> / '� ^72S <br /> CONTRACTOR 'ZS A j�-< ��«��'� /l,44- 9��{D PHONEyhc�/c3J ['�j� / <br /> CONTRACTOR ADDRESS _( D CITY/STATE/ZIP W06P <br /> SUBCONTRACTOR PHONE <br /> 1 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 157 El C-61 ❑ 70-09 ❑Other NUMBERS EXPIRATION DATE <br /> I GEOGRAPHICAL INFORMATWN: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE. DomesticrPrivate ❑ Irrigation/Agricultural ❑Industrial 0 Water Quality Monitoring ❑Soil Sampling/Characterization <br /> 0 Public Water System <br /> 1fdtferent from Owner. er QRl a(rIC arae or —N..be, <br /> TYPE OF WORK New Well D Replacement Well ❑Well AReration/Modification ❑Other \ <br /> ❑ Monitoring Welts) #of wells o Soil Boring(s) 4 of borings ❑Geotechnicai #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ` A <br /> 39QNew Pum El Pump Replacement 11 Pump Repair ❑Raise Well Casing (\� <br /> WELL CONSTRUCTION \�'1 <br /> Drilling Method "�Mud Rotary D Air Rotary ❑Auger n Cable Tool D Push Point ❑ Other W <br /> Proposed Well Depth 9-ft Excavation I-L In diameter ❑Open Bottom XGravel Pack/Gravel Size_ in diameter <br /> 0 Conductor Casing In diameter / Conductor Casing Depth it <br /> Well Casing Diameter-jrin Thickness/Gauge/ASTM Sched 2 2170 0 Steel Plastic D Stainless Steel 0 Other ((( <br /> ( Grout Seal Depth�0 ft ❑Neat Cement(94 lb bag/5-10 gal water) Sand Cement &( 3 sack mixR gal water <br /> IC Bentonite(20%solids) ❑Other <br /> Grout Placement Method]'Pumped ❑ Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 6mriller ❑Pump Contractor ❑ Other <br /> O Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box 11 Stove Pipe �l <br /> I PUMP <br /> _-,@%ubmefsibleO Turbine ❑Other HP Pump Set ft Standing Water Level It \ <br /> I HEREBY CERTIFY THAT 1 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 1N.COMPLIANCE WITH ALL.. <br /> WORKERS COMPENSATION LAWS. <br /> A MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS Igo- <br /> It <br /> SIGNED '�� TITLE W^'�/� DATE f <br /> Z <br /> I I - <br /> I <br /> - - Y <br /> f <br /> S N 0 0 t IN O <br /> TH DE 2W t <br /> t Application ate G�// Area Employee ID# <br /> Grout Inspection tem/��Gf ❑ SPECIAL Well Permit <br /> Pump Inspection B Date ❑ WAIVER Received <br /> ( <br /> I Soil Baring Inspection By Date Constructed WeH Depth ft <br /> COMMENTS /A��,.> <br /> PE SC Received hec Amount Date Permltl Invoice# Well ID# <br /> 1 Codes Info B Remitted Service Request# <br /> 3� ��o �­ s La(,-7 r <br /> o aso s.�m �i •� <br />