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11/05/2010 FRI 15: 29 FAX 2094693433 SJC EHD 0003/004 <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202•(209)468.5420 <br /> NUN-REFUNDABLE PERMIT CALL J2091 953-7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED <br /> _ <br /> JOB ADDRESS `- CITY)p, LA <br /> 20 C �' —3 <br /> _ _ /�' _ <br /> CROSS STREET <br /> Ali + PARCEL S72fi_�LAND USE APPLICATIONC <br /> OWNER NAME ,' 1 S C_f,, �, -y��V PHONE <br /> (> _7 I <br /> OWNER ADDRESS CITYISTATEfLP J�� G7� O <br /> CONTRACTORCTi �Y` T�P,HlONE <br /> 7 <br /> CONTRACTOR ADDRESS,�"r Y 1 i l� CITY)sTATeI� I/V I� L I�r `'` L/ <br /> SUBCONTRACTOR '"T •� CJ PtwNE <br /> +`` <br /> SUBCONTRACTOR ADDRESS^ILLI L� �tYS Imo! }"lAI/1�: IsTATEfZIP V�-.�_ <br /> LICENSE �:�G,S7 C-6t� D-09 L Other NUMBER EXPIRATIONDATE_ ) <br /> GEOGRAPHICAL INFORMATION: Coordinates Y Township, Range_____ Section_ N/A <br /> INTENDED USE 1 Domes9clPnvater :Irrigatkin/Agriculwral Industrial Waler Quality Monlloring Soii SamplinillCharacterization /7"� <br /> PuhVe Wafer S <br /> Oystem A 1)A <br /> fl blt�nM eon+ mwr a eTr am Mne M i V <br /> TYPE New Well ReplacementW'ell WegAlteraeon/Modflcalion �Oflie[,° EL Li,) CS <br /> S <br /> eoit»rrigr eabainaL ^ �I�� <br /> Monitoring Wats) M of Wells Soil Boling(s) Geotechnical <br /> Out-01-SeMce Well Out-Of-Service Web Renewal Cross-Connection Repan <br /> New Pump Pump Replacement .Pump Repair Raise Well Casing <br /> WELL coNsTRUcnON <br /> Drilling Method Mud Rotary Air Rotary Auger :Cable Tool Push Pant Other <br /> Proposed well Depth ft Excavation in diameter Open Bottom Gravel PackKosvel Size in diameter <br /> Conductor Casini in diameter / Conductor Casing Depth It 1 <br /> Welt Casing Diameter_n Th"nesslGauge/ASTM Sched ,Steel Plastic Stainless Steel Other �} / <br /> Grout Seal Depth R Neat Cement(94 lb bag/5-10 gat water) Sand Cement sack m xu gal water <br /> BerdonRe(20%sotfds) Other j <br /> Grout Placement Method .Pumped Free Fall .Other .Retardant/Accelerator(name) <br /> em—STAL Installed By Edge, Pump Cantraclor Other <br /> Concrete Pedesta)Dimension.VOdfh ft Length R Thick m jCibristyBox stovepipe <br /> PUMP <br /> Submensibi Turbine :Other HP Pump Set R Standing Water Level rt <br /> I HERESY 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 CONTRAMRS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION l S. <br /> V"H ADVANCE NOTICE. EQUIRED FO INSPECTION <br /> SIGNED_ TfiLE . Ti I'VA DATE € <br /> A 77"77 7- <br /> ►�e <br /> DEPARTMENT USE ONLY <br /> Appkcano 6 „l/i-+� Date Employee 10* <br /> Grout Inspection Dale SPECIAL Well Permit 9 n/1 <br /> Pump inspection By Date WAIVER Received 1 r'�9 y <br /> Soil Boning Inspection By Date_ Constructed Well Depth <br /> COMMENTS Noqi�/ <br /> PE SC Ra�ce�lved Checi Amount Data Perms Invoice p Well IOp L/� <br /> codes <br /> OInm IYIT `Ca sh 11 f�o t Son e Ra oast r h).RNMN Cpl/ <br /> Flys <br /> WELL A'UMPPEmAIT <br /> e/eVOa <br />