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WELL/PUMP PERMIT "u0003¢Sol <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS � _ CRY ZIPP/7�y1/ - D <br /> CROSS STREET L� 2GC�Z� PARCEL SIZE LANE)USE APPLICATION#ANtpo <br /> OWNER NAME r YVl Gl- ��j ✓�i'1rL S' _ _ PHONE <br /> OWNER ADDRESS Z ell UP Z-Cttl k."' _�.— CfTY/STATE21P <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS 1416121 r I4/ CfTY/STATE/ZIP111/1 ' fyS <br /> rr <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER_ EXPIRATION DATE Je!��/7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X_ YTownship Range. Section_ <br /> INTENDED USE Domestic/Private 3<rrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System___ __ <br /> It different armOwner: Iter System ame — �oMad Flame orFFone um r <br /> TYPE OF WORK ><New Well Replacement Well Well Afteration/Modification Other <br /> MonitoringWells #of wells Soil Boring(s)s w or bon gs <br /> O 9O- -- � Geotechnical _0 of bon <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodXMud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Deptl;l;?eCZ_it Excavation/J!f—in diameter Open Bottom Atravel Pack/Gravel Size 116-4in diameter <br /> Conducting in diameter / Conductor Casing Depth it <br /> Well Cast ng Di am r�Q in//Thickness/Gauge/ASTM Schad_2_JQ Steel}Plastic Stainless Steel Other <br /> Grout Seal D ih tt Neat Cement(94 Ib bag/5-f0 gal water) `Sand Cement sack mix/7 gal water <br /> Be to(20°ro solids) Other <br /> Grout Placement ethod Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ump contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length It Thick in Christy Box Stove PIPe <br /> PUMP Submersible Turbine Other HP Pump Set It Standing Water Level it <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 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 /> MINI UM 24 HOUR ADVANCE NOTICE REOUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED / ! i '/Q9'C�L� __ TITLE b V`t 1/,rn <br /> rA <br /> L ` <br /> IVV <br /> DEPARTMENT Y <br /> Acp!icatv�r.Ai�.ap:ou u oats AiaaAPECIAL <br /> =1_. Employ as ID* <br /> Grout Inspection _ Date Well Permit <br /> Pump Inspection By Date_ — J WAIVER Received <br /> Soil Boring inspection By Date Constructed Well Depth ft <br /> COMMENTS f A �I` ___ _= A <br /> PE Sc Reeeivetl Check#/ Amount Per'""' <br /> Codes Info B Cash Remitted Date Service Request# Invoice# .L ye11�1F 2 Q <br /> lei ✓�-R�12�'3 Q Q s <br /> N� <br /> 2w� <br /> � V <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />