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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> I t/1 <br /> y <br /> I JOB ADDRESS1-7,611 CITY/ZIP - nr <br /> ? pa <br /> CROSS STREET __,_APNT/ PARCEL SIZEJLAND USE APPLICATION# A <br /> OWNER NAME IPHONr�� <br /> OWNER ADDRESS +I CIry/STATE/ZIP_ tlodjY JR-1-- <br /> CONTRACTOR Bej _ PHOH <br /> ! CONTRACTOR ADDRESS CrrY/STATE/ZIP rX <br /> J N <br /> ! SUBCONTRACTOR PHONE <br /> SUBCONTRA ADDRESS rry/STATE/LP <br /> LICENSE I a-57 C C-61 ❑D-09 u Other NUMB ExPIRATION DATE <br /> " i <br /> GEOGRAPHICAL INFO ATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE ^PomestctPrivata F Irrigation/Agricultural n Industrial LI Water Quality Monitoring D Soil Sampling/Characterization <br /> U Public Water System <br /> If ditmrd from Owner water SySteM Narne Loontact Name or ne urriier <br /> TYPE OF WORK D New Well U Replacement WeII n Well Alteration/Modification L Other <br /> n Monitoring Well(s) #of wells D Soil Boring(s) #ol borings ❑Geotechnical ft or borings <br /> U Out-Of-ServiceII u Out-Of-Service Well Renewal I Cross-Connection Repair <br /> D New Pum Pum Replacement u Pum Repair <br /> WELL CONSTRUCTION i <br /> Drilling Method D Mud Rotary D Air Rotary n Auger n Cable Tool D Push Point 0 Other <br /> Proposed Well Depth ft Excavation in diameter U Open Bottom n Gravel Pack/Gravel Size in diameter <br /> n Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel L Plastic D Stainless Steel ❑Other <br /> Grout Seal Depth ft D Neat Cement(941b bag15.10 gat water) F Sand Cement saamix/7 gal water <br /> F,Bentonite(20%solids) 7 Other 1 <br /> Grout Placement Method n Pumped n Free Fall D Other U Retardant/Accelerator(name) <br /> -- I <br /> PEDESTAL Installed By ❑Driller 7 Pump Contractor U Other <br /> n Concrete Pedestal Dlmenslons:Width ft Length it Thick in ❑Christy Box D Stove Pipe <br /> PUMP Submersiblen Turbine ❑Other HP Pump Set ft Standing Water Level V11AU It <br /> I HEREBY CElifirIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIN STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE 1$ <br /> CURREN ND ACTIVE WI T CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL ' <br /> WORK S OMPENSATION AWS. <br /> INI 4 UR VANCE NOTICE REQ IR D FOR NSPECTIONS I <br /> $1GNED TITLE DATE j <br /> I <br /> 11 <br /> FN!Iv <br /> {{I <br /> 1 <br /> I <br /> 8 <br /> 7* 17 <br /> I <br /> SA 4 <br /> J A UI <br /> D�jARTM ENT USE O._ LYr <br /> Application Accepted w� � Date Q 0 Area Employee ID#,gw <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection B r--Date - LJ WAIVER Received <br /> Sall Boring IIns"pe�c`tion By Date Constructed Well Depth ft <br /> COMMENTS -�'72,J''I�'M� �Gt .c%T�J- G"-Ia i✓ /1LC7L-/�.L�GS lalr"�/IrG <br /> PE SC Rsoeived he Amount Date Permit/ Invoice Is Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> 1 o' 5' o kiPeo.2 30-7 <br /> EHU 4306 WELL'PUMP PERMrr <br /> 9.2&�7 <br />