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S � � <br /> r <br /> j WELUPUMP PEIrI'MIT `Q ILEU,Ci, ' <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT t 868 EAST HAZELTON AVENUE-STOCKTON C&9pW 468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> s ` fA <br /> m <br /> JOB ADDRESS I' CITY/ZIP L D <br /> �� v <br /> CROSS STREETV' 1' <br /> APN PARCEL SIZL�"dk AND USE A LIGATION# am <br /> OWNER NAME PHONLy <br /> OWNERADDRECITY/STATE/ZIP �J /l7 <br /> W <br /> CONTRACTOR11� 110C PHONE — nt <br /> CONTRACTOR ADDRESS CITY/STATE <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS ClTY/ TAT IP <br /> LICENSE 457 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE i i Domestic/Private Irrigation/Agricultural ❑ Industrial a �Quai Monitoring I Soil Sampling/Characterization <br /> Ll Public Water System _ <br /> If different from Owner: Water eft m Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/ o 'fication I Other <br /> of borings J—�►f�, #ings <br /> ❑ Monitoring Well(s)__-_ #of wells Soil Borings � Geotechnical— �� <br /> 1 Out-Of-Service Well Cl Out Of Se Ice Well R ne I ❑ Cross-Connection Repair RE`'`EVE,^ <br /> I New Pum i7 Pum Replacement =1 Pum e air ❑ Raise Well CasingD <br /> WELL CONSTRUCTIONPR U 7 2015' <br /> Drilling MethodMud Rota ❑ Air Rotary Auger r1 C le of Push Point I Other <br /> Proposed Well Depth. ft Excavation It dia eter Open Bottom Gravel Pack/Grave S IN CP(IN yer <br /> Conductor Casing in diameter / C nductor C ing Depth ft HEALTH DVJ�g NR TAL <br /> Well Casing Diameter_ in Thick ess/Gauge/ASTM c ed Ste�)Sand <br /> lastic Stainless Steel Other <br /> Grout Seal Depth_ 1 ft Neat ent b bag/5-10 gal water) Cement sackmix/7 gal water <br /> Bentonite(20%solids) ther <br /> Grout Placement Method Pumped II Free F I er rdant/Accelerator(name) <br /> PEDESTAL Installed By Driller F1 Pum C tr ctor Other <br /> Concrete PedesUl Dimension idth t Length ft Thick in Christy Box Stove Pipe <br /> PUMP ❑ Submersible i Turbine Othe HP Pump Set It Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREP.A, THIS PPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE L AN RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIF IA N ACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI MU 2H UR D A E OTICE REQUIRED F7, INSPE TION - PLEASE CALL(209)913-7p97 <br /> SIGNED TITLE1 I_ J DATE -1 <br /> 111 <br /> �`u;:. a .+e- .',,'�' -.�^-'e'. .�,. .w.-:rt,.e,•a . s. ... r.�,lt��"p,w{. Y,yl- "� <br /> 12 <br /> f <br /> NIS <br /> i i i i i 1 1 i i It <br /> DEPARTMENT USE ONLY p <br /> Application Accepted By �- UL — Date I Area �� c Employee ID# 5� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received �Checckk#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitte Service Re uest# <br /> A'7-�-Z t SGS /s - cz. I Ct CD <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />