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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 <br />%209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS / 2s �'t, . CITY/ZIP � <br />CROSS STREET / ��� I r C,L APN LG �Z _ _PARCEL SIZE�LAND USE APPLICATION # <br />Z <br />OWNER NAME /Wpff r1- _ PHONE &. 11-` " <br />5rj <br />OWNER ADDRESS 9/�A!M A /er CITY/STATE/ZIP r1 <br />CONTRACTOR /'��/,'/� V J� ? D��` _ _ PH E /yS�"yJ� S _��F` <br />CONTRACTOR ADDRESS I -l/ 4 CITY/STATE/ZIP • / • - "r <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE2IP <br />LICENSE 4' 7 C-61 D-09 Other NUMBERS f / J✓ y EXPIRATION DATE 1, <br />GEOGRAPHICAL INFORMATION: Coordinates X _ Y_ Township Range Section _ <br />INTENDED USE p11<omestic/Private Irrigation/Agricultural L. Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Nameymirtivh e tuber <br />TYPE OF WORK �Vew Well Replacement Well ❑ Well Alteration/Modification Oth�T� <br />I Monitoring Well(s) # of wells I Soil Boring(s) __ If of borings e # of borings <br />J Out -Of -Service Well I Out -Of -Service Well Renewal Cross -Connection Repair <br />e--wew rump i rump meplacemenr 1 1 rump mepalr Halse vvel uasing <br />WELL CONSTRUCTION <br />Drilling Method+<tvlud RotaryiA Air Rotary Auger I' Cable Tool Push Point Other <br />Proposed Well Depths C� _ <br />ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductol Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 6) in Thickness/Gauge/ASTM Sched Steel lastic I Stainless Steel Other <br />Grout Seal Depthklo ft Neat Cement (94 lb bag/5-10 gal water) and Cementsack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Methogj, Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By ;o ; Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in JLCt1j19Mjqo Pipe <br />PUMP -Submersible Turbine Other FiP.:.A Pump Set ft "nVg g r e e ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DO N 'A C H 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 />MINIMUM 24 OUR A VANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />SIGNED _ i- ._ TITLE [/ �/1''�� - DATE _ �7 -1 -- <br />T <br />D <br />0 <br />O <br />m <br />0 <br />DEPARTMENTUSEONLY <br />By y Area_qhcEmployee ID#Application Accepted <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Insection y <br />COMMENTS CAT Lc <br />(_nnatr r tura wan rinnfh <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />B <br />"__qtecW <br />Cas <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # Well ID# <br />/14 <br />J <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />