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WELL/PUMP PERMIT <br /> 1 It SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT <br /> CALL 109 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 26634 by 12 _ aTYmP Wallace Ca m <br /> CROSS STREET Comanche rd. APN 023-220-06 40x40 <br /> PARCEL SIZE LAND USE APPUCAT10N At O <br /> OWNER NAME PHONE 209-327-2439 0 <br /> OWNER ADDRESS OX lements Ca <br /> CITYIsTATFJZP <br /> CONTRACTOR <br /> Mark Fredrick Pump&Supply Co. PHONE 2092560364 <br /> -- <br /> CONTRACTOR ADDRESS CITY/STATEJZIP <br /> � ox ac so — <br /> PHONE <br /> ---- _—__ CITY/STATEJZIP <br /> LICENSE XC-57 XC-61 f}Qg Other NUMBER 333800 EXPIRATION DATE 9-3=14 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section_ <br /> INTENDED USE _:Domestic/Pnvale tmgation/Agricultural Industrial Water Quality Monitoring Soil Sampling Characterization <br /> ❑Public Water System <br /> Ir dillemnt hom Owner. er yc em amo on a ame or ITA u r <br /> TYPE OF WORK C New Well Replacement Well Well Alteration/Modification _ Other <br /> rl Monitoring Wells) A of welts Soil Borin s u"r b"`ngv Geotechnical x or hod"gs <br /> 11 Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> O New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point IOther <br /> Proposed Well Depth It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/GaugelASTM Sched Steel Plastic Stainless Steel 'I Other <br /> Grout Seal Depth ft Neat Cement(94 lb bagl5-10 gal wafer) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method -Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> - <br /> Concrete Pedestal Dimensions:Width ft Length ft1-hick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine - Other HP Pump Set ft Standing Water <br /> 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. I ALSO CERTIFY THA MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IIN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION L WS. <br /> SIGNED-/ <br /> MIN UM 24 ANetp6TICE REQUIRED FOR IN'ClEC/71 NS-PLEASE CAL (209)9 3-7697 <br /> 1 <br /> TITLE l / P/� <br /> vI� DATE <br /> ppYM <br /> REGE, <br /> APR 0' <br /> SAN JpACI <br /> ENVIR _ ll1e <br /> HEALTH Dfi <br /> s <br /> DEPARTMENT USE ONLY !' <br /> Application Accepted By / / A/��QC I Date4 � - area ��y Emplo a ID#_ <br /> Grout Inspection By Date SPECIAL Per it _ <br /> Pump Inspection By Date WAIVER Re ed /n/ / T <br /> Soil Boring Inspection By Date Constru yryepI th / / <br /> COMMENTS — <br /> I <br /> PE SC Received T Cha Amount Permit' <br /> Codes Info B as Remitted Date Service Request ff Invoice# Wet'IDS <br /> Eno 43-M <br /> 4/30/12 WELL/PUMP PERMIT <br />