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' WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEAH DEPT W / � 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> LL 9 95 <br /> NON-REFUNDABLE PERMIT ttA3-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br /> ' <br /> JOB ADDRESS CITYZP `(3' I^� <br /> CROSS STREET J APNysj o <br /> / PARCEL SIZFJ 7°-LAND USE APPLICATION>Ev <br /> OWNER NAME PHONE. fJ " <br /> OWNER ADDRESS r CITY/STATEILP <br /> CONTRACTOR +, / cl-PHONE 27 <br /> CONTRACTOR ADDRESS '/- CITY/STATEILP <br /> J <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEMP <br /> ' LICENSE ;).1-57 1 61 1 D-09 Other NUMB EXPIRATION DATE l' <br /> GEOGRAPHICALINFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE '✓DomestictPrivate - Irrigation/Agricultural I:I Industrial Water Quality Monitoring - Soil Sampling/Characterization <br /> ' Public Water System <br /> If different from Ormor water SyStOon Nnm Cool=Narne or one u r <br /> TYPE OF WORK q!•'New Well Replacement Well i Well Alteration/Modification i i Other <br /> y Monitoring Well(s) #of wells i Soil Boring(s) a of Wong- . Geelechnical y r l nonne:: <br /> Out-Of-Service Well I Out-Of-Seance Well Renewal Cross-Connection Repair <br /> ' < Iew Pump :Pump Replacement - Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 'Mud Air Rotary Auger I,Cable Tool -,Push Point Other <br /> Ra <br /> Proposed Well'Depth O R Excavation in diameter I Open Bottom Gravel Pack/Gravel Size �i ; in diameter <br /> ' Conducte Casing in diameter / Conductor Casing Depth If <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel i Other 1 <br /> Grout Seal Depth.;)2 b(n, It i Neat Cement(94 Ib bag/5-10 gal wafer) }(Sand Cement sack mixl7 gal water N <br /> Sentonite(20%solids) _I Other _ <br /> Grout Placement Method i ,umped a Free Fall i!Other J Retardant I Accelerator(name) <br /> ' PEDESTAL Installed By 100riller Pump Contractor F Other s N <br /> Concrete P este)Dimensions:Width R Length R Thick in ,i Christy Box C.Stove Pipe <br /> uYP Submersibleu Turbine a Other HP= Pump Set (t Blanding Water Level it nl <br /> ' I HEREBY C TIFY 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. 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 /> PINI 24 HOUR ADVANCE NOTICE QUIR D FOR INSPECTIONS <br /> :2& TITLE r, DAT <br /> SIGNEDE <br /> ' - C s `• <br /> - e �tfy _ �IMENT <br /> ' 1 CEIVED <br /> s _ 1 7 2012` <br /> ' - COUNTY <br /> msn <br /> NERAL <br /> cPARTYAENt <br /> DEPARTMENT USE ONLY <br /> ' Application Accepted By ale ? Area Employee IDT ( ' ` <br /> Grout Inspectionale SPECIAL Well Permit <br /> Pump Inspection Date WAIVER Received <br /> ' Soil Boring Inspection By Date Constructed Well De Ih ft <br /> COMMENT S C./�u <br /> fir;1TV y /' tr 6- <br /> i <br /> ' PE SC Received Check#! AmountDato Permit! Invoice# Well ID# <br /> Codes Info B Cash Remitted Serviee R uest# <br /> ' EHD d3-nG <br /> 81041118 WELL/PUMP PERMIT <br /> -f-s'v Ali <br />