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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,^ / to <br /> 2 �G� ,l� CITY/ZIP SC Q m <br /> JOB ADDRESS l_-�=y--1�� yI 1 L � <br /> n <br /> �7-OZo- ° <br /> CROSS STREET_ APN PARCEL SIZE LAND USE APPLICATION _ m <br /> OWNER NAME Lt ��/"�D � L� PHONE <br /> OWNER ADDRESS jj CITY/STATE/ZIPS�c>L 0�1^ <br /> CONTRACTOR 5 ��1 It L124% PHONE �7 Ze <br /> CONTRACTOR ADDRESS i ('"1/� / Rd CITY/STATE/ZIP S �l <br /> rr <br /> SUBCONTRACTOR _ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 `I C-61 D-09 U Other NUMBER EXPIRATION EXPIRATIONDAT ________ _ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br /> INTENDED USE Domestic/Private r: Irrigation/Agricultural t1 Industrial Cl Water Quality Monitoring U Soil Sampling/Characterization <br /> i I Public Water System <br /> If different from Owner: Water System Name contact Name or Phone Number <br /> TYPE OF WORK XNew Well I i Replacement Well ❑ Well Alteration/Modification U Other <br /> ❑ Monitoring Well(s) Of of wells ❑ Soil Boring(s) #of borings I_ Geotechnical #of borings <br /> ❑ Out-Of-Service Well [i Out-Of-Service Well Renewal a Cross-Connection Repair <br /> P, New Pump Pump Replacement ❑ Pump Repair U Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary Ci Air Rotary Auger U Cable Tool LI Push Point U Other <br /> Proposed Well Depth ft Excavation �_ in diameter -1 Open Bottom Vravel Pack/Gravel Size in diameter <br /> LI Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in ckness/Gauge/ASTM Sched L D O rJ Steel �1'lastic U U Stainless Steel Other <br /> Grout Seal Depth Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mia17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method><Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By CI Driller Pump Contractor 1 Other <br /> Concrete Pedestal ;Dimensions:Width ft Length ft Thick in Christy Box n Stove Pipe <br /> PUMP Submersiblef I Turbine I Other HP Pump Set ft 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209)953-7697 <br /> SIGNED TIJLE DATE <br /> i ^ , 11^^ <br /> •1 <br /> 771 1 <br /> 1 <br /> r I' <br /> r = <br /> C UJ_A .1 ONVIR TA <br /> I <br /> I 1 1 1 1 1 1 1 ?1 1 1 1 1. IT <br /> Df" <br /> DE ARTMENT U E 9N Y <br /> Application Accepted By Date j--- y AreaEmployee ID#r 4_q�7 � <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date_ Ci WAIVER Received <br /> Soil Boring Inspection By _ Date Constructed Well Depth ft <br /> COMMENTS C�z����y lir/ ,l -G <br /> v <br /> PE SC Received Check#/' Amount Date Permit/ <br /> Invoice# Well ID# <br /> Codes Info B �Eash Remitted Service Request# <br /> I x�r h <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />