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-it, t; <br /> WELUPUMP PERMIT <br /> SAN JOA03IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT /CALL <br /> (209)953--76f9�7 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS J ' G ► NL 4',/� CITY/ZIP �t` I � m <br /> D <br /> CROSS STREET" �' l/r APN PARCEL SIZEAND USE APPLICATION# <br /> / <br /> OWNER NAME `� L `!'---� PHONE �/Jt/'�n�(-� <br /> OWNER ADDRESS n CITY/STATE/ZIP <br /> CONTRACTOR �rl PHONE L <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP [� <br /> SUBCONTRACTOR j6J010 ,26�/{ U`n PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ' / <br /> ti/G57 C-61 D-09 Other NUMBER � � J S� EXPIRATION DATE_ L /� <br /> GEOGRAPHICAL INFORMATION: Coordinates X_ YTownship Range Section <br /> INTENDED USE '--<bomestic/Private Irrigation/Agricultural ❑ Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name --------CoAact Name or Phone Number <br /> TYPE OF WORK ,flew Well replacement Well ❑ Well Alteration/Modification Other <br /> 'I Monitoring Well(s) #of wells ❑ Soil Boring(s) 1 <br /> #of borings Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal J Cross-Connection Repair <br /> ,.V—New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method`<Mudd Ro ary 7 Air Rotary Auger r, Cable Tool Push Point F Other <br /> Proposed Well Deptft Excavation 1,L_ _ in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 1�_ in Thickness/Gauge/ASTM Sched ZoI� Steel XPlastic Stainless Steel Other <br /> Grout Seal Depth !ea ft Neat Cement(94 lb bag/5-10 gal water) >,Sand Cement 0 sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Methods Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By >ZDriller Pump Contractor F Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick 6 in 1 Christy Box Stove Pipe <br /> PUMP ubmersibie Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT�! 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNT i vriuii ANCES, STATE LA'VVS, AND RU;-E^- AND REGUL_AT iCNIC. ALSO "ERT.=Y THAT F;EQU:P.EDIS <br /> Liv V. <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 4 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209)953-7697 <br /> � <br /> SIGNED- L��✓ �"� TITLE �''v�� DATE � <br /> J <br /> zw <br /> a <br /> LT <br /> DEPARTMENT USE N L Y <br /> .c D.. O �at� cm to ee iD# <br /> Grout Inspection y Date*Z�- - iJ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection @y Date Constructed Well Depth ft <br /> COMMENTS Aofl 1JQ o, O <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Request# Invoice# Well ID# <br /> 3q `32667 ??` WPOAP1492 <br /> 260 0 `36 <br /> 3 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />