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a <br /> WELUPUMP PERMIT <br /> 12AN JOADUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> f 1/Gl (em <br /> JOB ADDRESS t.5 _ CITY/ZIP M <br /> A <br /> CROSS STREET ! APN D4)/ PARCEL S¢EID USE APPLICATION# r m <br /> OWNER NAME I ,1 PHONE- J <br /> OWNER ADDRESS Oo CrrY/STATEizIP <br /> di <br /> CONTRACTOR PHONE O <br /> CONTRACTOR ADDRESS / /t CITYISTATEIZIP �, <br /> SUBCONTRACTOR )� tt PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEgJP OQ <br /> LICENSE C-57 61 ❑D-09 ❑Other NUMBER EXPIRATION DATE 3 l d <br /> GEOGRAPHICAL INFORMA N: Coordinates X Y Township— Ranae Section_ M <br /> INTENDED USE ❑DOmestlC/PrivateMgation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> 0 Public Water Sys m <br /> Vdifferent from Owner. Water SysteM Nam CON=Nam or PtWM NuMbr <br /> TYPE OF WORK ❑New Well Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of h0/1ngs 0 Geotechnical #orbodngs <br /> ❑Out•Of-Servioe Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑New Pump P <br /> pfum Re lacement ❑Pum Repair ❑Raise Well Casing <br /> WELL CONSTRUC71O�N <br /> Drilling Method Mud Rotary <br /> ❑Air Rotary 0 Auger ❑Cable Tod ❑Push Point 0 Other <br /> Proposed Well Depth Zv It Excavation _in diameter ❑Open Bottomravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter/0-in Thickness/Gauge/ASTM SchedzLza9❑Steel 0elastic D Stainless Steel ❑Other <br /> Grout Seal Depth�2 ft ❑Neat Cement{941b bag45-1D gal water) �❑"Sand Cement sack mixt7 gal water <br /> 9-tonite(20%solids) 0 Other <br /> Grout Placement Method XPumped 0 Free Fall ❑Other O Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Pump Contractor 0 Other <br /> ❑Concrete Pedestal Di rasions:Width ft Length ft Thick in 0 Christy Box ❑Stove Pipe <br /> Purty ❑ ubmersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CE IFY 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 /> MIN U OUR ADVANCE NOTICE¢�E§lRE9 FO <br /> }2 INSPECTION DATE <br /> SIGNS TITLE 'I e l��— <br /> ! 7 <br /> 1 <br /> S - 06 1 e.� s > 41 <br /> - - e 0 C'v <br /> Gds/ - <br /> - I - <br /> i N <br /> 2 E VL ART £ <br /> - - - - - " _� -- — - D A MEN U -E N�/LY <br /> Application Accepted /J Date �� �O OO Area ©�! // Employee ID# f <br /> Grout Inspection B Gam. Date �� �' ❑ SPECIAL Well Permit <br /> Pump Inspect 1 ❑ WAIVER Received <br /> Soil Boring Inspection B Date Constructed Well Depth It <br /> COMMENTS cft C' G3L' ?GIGSI��=�.tJ GYi2�r.J JJ/�tsZo�L Jf �f SC —2S/J/l/s/ <br /> PE SC Received Check#/ Amount ParmrU <br /> odes Info B Date Remitted Service R invoice# Well ID#Request# <br /> OS'.b - Sa W ova9 5/9/ <br /> EHD 43061�/I B J �L� u�' � ELL!PUMP PERMR <br /> 8104r„8 f/�� <br />