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WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> -/ to <br /> JOB ADDRESS 40 CITY21P m <br /> CROSS STREET <br /> :t�z APN Z!2 3'070 tJ 2 PARCEL SIZE 11-�) LAND USEj APPLICATION# � <br /> OWNER NAME Ir 7'17ja PHONE r <br /> OWNER ADDRESS M41 <br /> CITY/STATE/ZIP <br /> � <br /> CONTRACTOR � �� S'�Lr/ �,J PHONE R- OFT( / <br /> CONTRACTOR ADDRESS-E.01 //� ! CITY/STATE21P <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE .4-C-57 .. C-61 D-09 Other NUMBER 4U21--ac-2LEXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: C.141r ateS X Y Township Range Section_ <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water yslem ame Contact Name or one um r <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) If ga of borings of wells Soil Boring(s)s)...__ Geotechnical M of borings <br /> XOut-Of•Service Well _ Out-Of-Service Well Renewal - Cross-Connection Repair <br /> New Pum . Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary . Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft 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/Gauge/ASTM Schell Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) 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 /> Concrete Pedestal Dimensions:Width it Length it Thick in Christy Box . Stove Pipe <br /> PUMP Submersible_ Turbine Other HP Pump Set it 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 LA <br /> MINMUM 24 HO DV E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76697 <br /> SIGNED TRL !7 E 'gg 7 � DATE , :- rq'7 - 12- <br /> Z <br /> E <br /> _ 41 <br /> DEPA TMENTT /vY <br /> Application Accepted By � • Date � Area Employee ID# <br /> Grout Inspection By_ Date L SPECIAL Well Permit <br /> Pump Inspection By. Date WAIVER Received <br /> Soil Boring I cticn By Dat Constructed Well Depth it <br /> COMME TS <br /> D <br /> PE Sc Received Checkl� Amount PermlU <br /> Codes Info B ash Remitted Date Service Request IN Invoice# Well IDA, <br /> o s7 o bqqqz. <br /> FNA�11G ...�.. ...........-......� <br />