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WELUPUMP PERMIT <br /> SAN JOA03IN 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 J [ / /1/L�l/� L'� CITY/ZIP '�`��i � Z�� m <br /> Gr+ D <br /> CROSS STREET APN , C� _PARCEL SIZE AND USE APPLICATION# a <br /> OWNER NAME ` L /' PHONE GV J l LxJ y <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR �� 1-1-11X PHONE 23-:3 <br /> 1 Jig <br /> CONTRACTOR ADDRESS A �(� CITY/STATE/ZIP <br /> SUBCONTRACTOR a)o C—1 /J' PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP /� <br /> LICENSE ti/C-57 C-61 D-09 Other NUMBER 7.5 S EXPIRATION DATEU /7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE '-d<Domestic/Private Irrigation/Agricultural ❑ Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Name ontact Name or Phone Number <br /> TYPE OF WORK 3,�Iew Well .,N<heplacement Well ❑ Well Alteration/Modification Other <br /> ) Monitoring Well(s) If of wells ❑ Soil Boring(s) __ a of borings Geotechnical a of borings <br /> I Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> >1 New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method's Mu�dq Ro ary ❑ Air Rotary Auger o Cable Tool Push Point n Other <br /> Proposed Well Dept h-r 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 1� in Thickness/Gauge/ASTM Sched Steel XPlastic Stainless Steel Other <br /> Grout Seal Depth_Zoo ft Neat Cement(94 lb bag/5-10 gal water) >.Sand Cement --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 >eDriller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thickin Christy Box Stove Pipe <br /> PUMP ubmersible Turbine Other HP Pump Set ft 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 TY - RD; • CEG ` C `n G . �1C zl CE97:=Y THAT !��`; FRE 1 !CE 1 <br /> COUNTY VclUll'�iM{VVCJ� $TAT' L:,i'r'.. i,id::� RULE-- :,P.v ^nEsJL..TiC r.,. .-,� 0 �?'-'r OL+iR=D i,,,�!`Sc I <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIUM 4 UR ADVANCE NOTICE REQUIRED FOR <br /> q INSPECTIONS - PLEASE CALL (209)953-y7�7697 <br /> SIGNEDL �!L_v`� TITLE �+ DATE <br /> J <br /> F- <br /> Z <br /> LILL <br /> a <br /> IP <br /> _ a <br /> DEPARTMENT USE N L Y /} <br /> �� G1l11 <br /> y •ato _ tiicd_ 1 1 1 1 CnlplOyee IUS <br /> Grout Inspection y -' Date 1 i��l SPPECI'ALL Well Permit <br /> Pump Inspection By 1-� Date % (�`� WAIVER Received <br /> Soil Boring InsPection Dy Date Con tructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request If <br /> 0 50 3 (o 5 �� <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />