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WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT (\1T CAUL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE TISSUED <br /> JOB ADDRESS 1 J` �1& Cm21P / 7�/`� n' <br /> T /�� D <br /> CROSS STREET �,`� .�\ APN� -{/TT CiJV! Q0 PARCEL SIZE a O AND USE APPLICATIIOON,�# m <br /> OWNER NAME .�\ I''r('I.r I"I l PJ(LI�`�I QI (D7� ��1P✓HHONE 9�1,� [V'T (Yf y)1 y <br /> OWNER ADDRESS l�yyiL _! G ! _�l CITY/STATE/ZIP Y /*-� -I <br /> CONTRACTOR �/ PH�OgNE.q—oq L hY <br /> CONTRACTOR ADDRESS r / CfrY/STATE/ZIP D/`1 K-bL e /"4 S�& I <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS C <br /> yI <br /> �TY/STATE/ZIP / <br /> LICENSE C-57 C-61 ' D-09 Other NUMBER Lei � r - EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sam pling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name UortactNameorPhone Number <br /> TYPE OF WORK New Well Replacement Well : Well AlterationtModification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of bons Geotechnical #of bonngs <br /> Out-OfService Well Out-0f-Service Well Renewal Cross-Connection Repair <br /> New Pum <br /> 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 Schad Steel ' Plastic Stainless Steel _- Other <br /> Grout Seal Depth ft Neat Cement(94 lb bagl5-10 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 ft Length ft Thick in Christy Box Stove Pipe /1 (� <br /> PUMP Submersible Turbine - Other HP Pump Set ft Standing Water Level ft 6��IVC® <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAS c <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE 161 T ' 0 2019 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL U <br /> WORKERS COMPENSATION LAWS. <br /> M �I1MU r'24 HO ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209 9 3-7 97 ��� QUIN CpU <br /> SIGNED ,/ I - TITLE I/'^'r l�- DATE ) ( HEA pEpgRT LN� <br /> 1 I <br /> 77> <br /> Y <br /> PA TMENT USE 9NLY <br /> Application Accepted By Date Area Employee ID#L—'2 LLJr/l6�'i <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By �li')ci C��n Date i�- I at I \tA ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth it <br /> COMMENTS <br /> PE SC Received -�-CtI Amount Permit/Codes Info B Cash emitted Date Service Request# Invoice# Well ID# <br /> o �b 10700 -7 <br /> EHD 4306 WELL/PUMP PERMIT <br /> 4/30/12 <br />