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c <br /> WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(208)468-9420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> S <br /> I I w. 1J �'CUI c. OCi�Oh CA C(9-20 <br /> m <br /> JOB ADDRESS s <br /> CROSS STREET Cda• v 11 , APN i I 1 S O-0 ARCEL SIZE 10 "U.USE APPLICATION`#, ? 1 rnb <br /> OWNER NAME O V(yl CAJJ f C� PHONE 2-� 73 .J- t 2 J <br /> OWNER ADDRESS-�7�,Q,, 'A,/,.yA Jp pI C�rrY/$TATE21' \ ( --. <br /> CONTRACTOR yi 1I/�V I^(MV�� Well <br /> -t ri �� "•L P/Ho ��,• .r`� <br /> CONTRACTOR ADDRESS �_1 IAJV/r�Yn l7 1 CLI J✓�/1 YLI� CIT//$TATE21P V�,{�L <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/$TATERIP / <br /> LICENSE 57 C61 D-09 Other NUMBER ExPIRATIONDATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section_ <br /> INTENDED USE DomesbctPrivata nigation/Agricuttural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Pudic Water System <br /> If dMerem ham Owner Water System N8M eme or Fhofre Number /1 <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil BoringN of boring <br /> s) s Geotechnical #of borings <br /> Out-Of-Senece Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method tMud Ro Air Rotary Auger/,/,�Cable Tool Push Point Other E <br /> Proposed Well pth it Exca bon ^ in diameter Open Bottom Gravel Pa&JGravel Size in diameter <br /> Conduct r Casing in diameterT/ Conductor Casing Depth ft <br /> Well Casing Diameter In Thirkness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth `� ft Neat Cement(94 Ib bay5-10 gal water) )rSand Cement �Y7. sack morn gal water <br /> Bentonite(20%solids) Other � <br /> Grout Placemerd Method Pumped Free Fail Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length It Thick in Christy Box Stove Pipe 1 /\ <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level <br /> I HEREBY 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 AC E WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEN TION LAWS. <br /> MINI UR/^A'DT�'/ T EQUIRED FOR INSPECTIONS elm <br /> CALL(209)953I-7697 <br /> SIGNED I TITLE \ •� 7'1'PVr`"' DATE o6l .?4a <br /> )( 4I <br /> UIV If I he 1 11 Ll <br /> RFS NF T <br /> D <br /> AUL, ?014 <br /> DEPARTMENT USE ONLY <br /> ar' <br /> Application Accepted By °1�7 r � Date -7110114 AreaDC �J Employee ID# <br /> Grout Inspection By Date Well Pennft <br /> Pump Inspection By Date - WAIVER Received <br /> Soil Boring Inspection B Date Constiuctad Well Depth R <br /> CQMMENTS ol <br /> di t—%rc-itf <br /> PE SC Received Amount Dab Pennitl invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> 436ti 1 gD b + <br /> EHD 43-M WELL HUMP PERMrr <br /> 49th 2 <br />