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WELUPUMP PERMIT <br /> SAN JOAQUIN 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 /> 210�1JOB ADDRESS' ' CITY/ZIP 1 L�fT C�/ <br /> CROSS STREET ��/`,�,� / (�! API V PARCEL SIZE QAND USE APP # <br /> OWNER NAME IVII- �'E; PHONE-7/fLICATION <br /> OWNER ADDRESS �-�` I i AV, S CITY/STATE/ZIP / 0 <br /> CONTRACTOR x i4 �� C Q`v &-.Z 1 IPHONE <br /> + J� � <br /> CONTRACTOR ADDRESS(0(/� �r/�l CITY/STATE21P ,,/ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 1.6-57 C-61 D-09 Other NUMBER n S EXPIRATION DATE -[ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private rrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name ontact Name or Phone Number <br /> TYPE OF WORK ellew Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) If of wells Soil Boring(s) a of borings Geotechnical n of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> �Oaew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method '�+lud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom ></G ravel Pack/Gravel Size in diameter <br /> Conduc r Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diametern in Thickness/Gauge/ASTM Sched 2.21 Steel ►Plastic Stal e s Steel Other <br /> Grout Seal Depth72 -30 ft Neat Cement(94 lb bag/5-10 gal water) "band Cement sack mW7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method b4umpecl Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By >6riller Pump Contractor, Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in 1 Christy Box Stove Pipe <br /> PUMP P<Submersible Turbine Other HP t> 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 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 /> �� Ww <br /> ATITLE(i DVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED ,� ` t /y <br /> (.'y�� ATEA <br /> L <br /> -41 <br /> Al <br /> tu <br /> NA <br /> i; <br /> L ' <br /> E VR <br /> A T D P R M <br /> DEPARTMENT USE ONLY <br /> Application Accepted By e(// Date Area Q O qcj Employee ID#AcaffD <br /> Grout Inspection By Date CI SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> So:'Boring Inspection By _ Date Con truct d Well Depth o2 ft <br /> COMMENTS 414 e 04 <br /> PE SC Received Check#/ AmountermiU <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> ILMI Kb 3 1 --- 14 4 Scu)o 7119'? <br /> �3�a Sv �� e 3 5 3-- ► ►� ►� � /9a <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />